Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

This patient is a female gravida (G) 2 para (P)1 who presented at 34-1/7 weeks gestational age. The patient presented with an evaluation for left lower quadrant pain since the evening. She reported that it started suddenly with a pain scale 8 of 10 that was 5 by the time of her presentation. There was nothing that seemed to make it better or worse and it was constant. The patient denied leaking fluid, vaginal bleeding, decreased fetal movement, dysuria, constipation, diarrhea, or nausea.
The patient's antepartum course was noted for gestational diabetes and obesity. She was managed on diet only for gestational diabetes. The patient was also of advanced maternal age and had normal prenatal screening. There was a right adnexal cyst noted on ultrasound in the antepartum course. The cyst measured 2.5 by (x) 5.9 x 5.1 centimeter (cm) in May. The infant was large for gestational age at 99th percentile by ultrasound in the office. The patient was a nonsmoker and did not use alcohol.
The patient's blood pressure at presentation was 132/64 with a heart rate of 81. The body mass index (BMI) was 40 kg/m2. Her physical exam for the abdomen was soft, nontender with no rebound or guarding. The uterine fundus was soft and nontender. The uterine sized greater than dates. The fetal heart rate was reassuring with a baseline of 135 with moderate variability and no decelerations.
The patient was admitted at 34 weeks with possible preterm labor and preterm contractions. Contractions were described as every 6 minutes. The patient was also seen by maternal fetal medicine on the morning following presentation. Maternal vital signs remained stable. An amniotic fluid volume was 25.66 with mild polyhydramnios. The patient's fetal monitoring remained stable and vital signs were normal. The patient was cleared for discharge to home with follow-up in the outpatient setting. Fingerstick blood glucose had been normal during hospitalization with a blood glucose of 96. There was no cervical change documented during hospitalization.
At issue is the medical necessity of the Inpatient Hospital Admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
Based upon a review of the medical records, and the recommendations of the American College of Obstetrics and Gynecology (ACOG), there would have been no medical necessity for an acute inpatient level of care. In this case, the patient was noted to have a singleton gestation at 34-1/7 weeks gestation with threatened preterm labor. There was no cervical exam on admission to document the cervix by the physician. However, given preterm contractions, a plan was made for ultrasound, IV fluids and observation. The fetal monitoring was reported as normal and reassuring with a singleton gestation. The ultrasound noted mild polyhydramnios in the setting of known gestational diabetes-A1. The patient, at this gestational age, was not indicated for steroids, tocolysis or magnesium.  There was no vaginal bleeding present, and the fetal status was reassuring. There was no inability to stop preterm labor as the patient was noted to have no cervical change and remained closed, 0% effaced and -5 station on the following morning. This is in agreement with the recommendations of the ACOG.
Therefore, the Inpatient Hospital Admission was not medically necessary for this patient.