Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Monitored labor pains following cervical cerclage removal
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The determination is upheld.

This patient is a female who was admitted to the hospital for pain after removal of cervical cerclage. The patient is 36 weeks, 6 days gestational age with prior history of Preterm premature rupture of the membranes (PPROM)/preterm labor with a McDonald cerclage in place. The patient presented for cerclage removal. The patient denied contractions, vaginal bleeding or leakage of fluid. She endorses normal fetal movement. The patient was also status post vaginal progesterone with cerclage in place since 20 weeks. The patient's past obstetrical history was noted for prior preterm rupture of membranes and preterm labor at 36 weeks. She denied history of gestational diabetes, preeclampsia or postpartum hemorrhage. The patient had no significant past medical or surgical history. Medications include a prenatal vitamin and the patient has no allergies. The patient's diagnosis was cervical insufficiency in the second trimester with cerclage in place. Her vital signs at presentation were stable with the patient being afebrile at 36.6 Celsius (C) with a heart rate 97, respirations of 18 and her blood pressure was 118/72. Uterine activity was noted to be absent. Fetal monitoring was category 1 and reassuring. The patient had an ultrasound that showed a vertex presentation with 11 centimeter (cm) amniotic fluid volume. She had a singleton gestation. The patient presented for removal of cerclage. She was taken to the operating room and cerclage removal that was done without complications. The plan was to discharge the patient home when recovered, if not dilated more than 2 cm and no evidence of overnight dilation and progression of labor. She had an estimated blood loss of 2 milliliter (mL). 100 cubic centimeter (cc) of fluid was given to the patient. The Prolene suture was removed without difficulty. Following removal of the cerclage the patient was 3-4 cm, 80 percent (%) effaced and -3 station. The patient was taken to labor and delivery in stable condition. The patient was monitored by anesthesia and was noted to have stable vital signs throughout the procedure without any complications. Initially, the patient was noted to have contractions after removal. Contractions were every 9 minutes with a pain level of 2 of 10 on the pain scale with each contraction. The patient was noted to have no change in her cervix over time and had no indication for repeat vaginal exam. She was given oral hydration and the plan was made for reexamination in the morning if there was a change in status. Fetal testing remained reassuring without complications. On the following day, the patient was 37 weeks gestation and her contractions had spaced out. She was having these every 9 minutes with very little pain. She was feeling well and her category 1 tracing continued with fetal reassurance. The patient was discharged to home and was scheduled for induction of labor at 39 weeks.

In this case, the care provided for cerclage removal and fetal monitoring would not have required admission to acute inpatient level of care as based upon the Milliman Care Guidelines (MCG) Obstetrics & Gynecologic Surgery or Procedure General Recovery Guidelines (GRG) or Preterm Labor or Threatened guideline. In this case, the removal of a cervical cerclage could have been performed at the ambulatory level of care. There was no excessive bleeding, concern for fetal status or complications of removal of the cerclage or labor. There was no indication for ongoing fetal monitoring given a reassuring status. There was no concomitant severe maternal disease present.