Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Intrauterine growth restriction (IUGR)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a gravida (G) 4 para (P) 2 012 who presented at 40-5/7 weeks gestation with intrauterine growth restriction (IUGR) and oligohydramnios for plan of induction of labor. The patient was dated by first trimester ultrasound. She had a body mass index (BMI) of 30.1 kilograms per square meter (kg/m2). She had a heart rate of 91. She was afebrile at 98.3 Fahrenheit (F). She was noted to have a significant history of chronic hypertension (on no medications in pregnancy) with prior open heart surgery due to coronary artery dissection. She had a single vessel involved - the left anterior descending (LAD). She had a single vessel graft completed. The last ejection fraction by echocardiogram was 45%. The patient was also of advanced maternal age and had normal screening by non-invasive prenatal screening (NIPS) testing. She had a possible fetal ventricular septal defect (VSD) on ultrasound. She was group B strep (GBS) positive. The patient was a non-smoker. She was noted to be IUGR with oligohydramnios at presentation and a plan was made for induction of labor. Blood pressure was 136/95. She had a cervical exam of 1 centimeter (cm) / 0% effacement and -3 station. The exam was normal. Fetal status was reassuring with Category I testing. Ultrasound of the fetus noted a 6 pound 7 ounce fetus in vertex presentation. The amniotic fluid index (AFI) was 2.83 cm with no 2 x 2 pocket present. The patient was seen by cardiology and a repeat echocardiogram was completed with a decreased ejection fraction of 35%. Given this change in cardiac function and counseling that the recurrence of dissection can be 25-50%, the patient was determined to be at high risk for fluid overload, pulmonary edema, recurrent dissection and delivery was canceled and recommended at a tertiary care center. Thus, the patient was transferred for care. The patient underwent transfer to the separate facility for plan of delivery. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

In this case, upon review of the medical records and the care provided in concert with the peer reviewed literature, there would be no medical necessity for admission to acute inpatient level of care for evaluation. In this case, the patient was planned for delivery by induction of labor leading to a vaginal delivery. The fetus was noted to be IUGR with oligohydramnios at term which would be an appropriate plan. However, in this case, the patient underwent an echocardiogram as a result of the significant health history of an abnormal prior echo after maternal coronary artery dissection of the LAD with graft repair at open heart surgery. Given this history, rather than undergo an induction of labor, the patient was ordered for an echocardiogram to be completed and this was noted to be abnormal, with depressed function at 35%. Given this finding and the counseling on recurrence risk for dissection, risk for volume overload and pulmonary edema, and risk for cardiac complications in labor, the plan was discontinued, and the patient was to be transferred to a higher level of care at an outside hospital for delivery. There was no indication to support admission to the acute inpatient level of care in this case for the provision of cardiac workup and fetal non-stress test (NST) as provided.