Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient Stay.
The denial is: Upheld in whole.

This patient is a gravida (G)2 para (P)1 living (L)1 who presented at 30-6/7 weeks gestational age with complaints of back pain since the night prior. The patient reported she had a fever of 100.5 Fahrenheit (F) at home with some cough and shortness of breath with tightness of her chest with palpitations with her cough. She stated that she had a child at home with fever since the day prior. She had not taken any medications for her fever. She denied any abdominal pain, vaginal leaking of fluid or vaginal bleeding. She denied any headache, blurry vision, or epigastric pain. The patient denied any past medical history. The patient had a previous history of cesarean delivery. She was taking a prenatal vitamin daily. She had no known allergies. The patient was married and was a former smoker but had quit. She had no prior international travel.

The patient's temperature at arrival was 99.3F with a heart rate of 118. Blood pressure was normal for pregnancy throughout her stay in the 80-100's over 50's diastolic. She remained mildly tachycardic. Oxygen saturation levels remained stable in the 96+%. Fetal status remained reassuring. The patient's examination noted her to be alert and oriented and cooperative with exam. Her heart was regular rate and rhythm with tachycardia and palpitations resulting in an electrocardiogram (EKG) being performed. The lungs were clear to auscultation. The abdomen was soft, nontender with bowel sounds normal gravid uterus. The size of the uterus equals dates and there is no costovertebral angle (CVA) tenderness. Lower extremities were symmetric and nontender bilaterally. There is no evidence of deep venous thrombosis seen on physical exam. The patient was admitted with the plan of external fetal monitoring to be performed continuously. Vital signs monitoring was planned. A portable chest x-ray was planned with abdominal shield. Labs were sent for type and screen, complete blood count, operates a metabolic panel and a thyroid stimulating hormone (TSH). Tylenol was given for pain and fever. An influenza culture was ordered. Intravenous (IV) fluids were started. Arterial blood gas, blood culture and sensitivity, urinalysis (UA) and urine culture and sensitivity were all ordered. A medicine consult was ordered. Internal medicine noted that the patient had a prior history of tricuspid regurgitation. She had the reported sick contact of her son with an upper respiratory infection. She had a negative influenza swab. She had a normal arterial blood gas (ABG) for pregnancy (normal is respiratory alkalosis) which was seen on her exam. She also had a normal white count and normal complete metabolic count. Gonorrhea and chlamydia were negative on assessment. Coagulation studies were normal. Blood culture and urine culture were negative. The patient had a maximum temperature 100.2F at 1716 p.m. and was afebrile since that time. She had signs of upper respiratory tract infection. The patient's chest x-ray was negative. Blood cultures and urine cultures were collected. EKG showed sinus tachycardia. Influenza screening was negative. Internal medicine was consult and recommended starting the patient on a Z-Pak and Tamiflu. She was started on 500 mg of azithromycin as well as 75 mg of Tamiflu daily. Fetal heart rate showed some variable decelerations with spontaneous root covering and resolution. Rupture membranes and chorioamnionitis were excluded. Gonorrhea and chlamydia as well as GBS swabs were collected. The patient was asymptomatic on the discharge day/hospital day one expressed her desire to be discharged. The patient's fetal heart tones were category 1 with a baseline of 145 beats per minute with moderate variability. There were no contractions noted. The patient had been afebrile for 17 hours by the time of her discharge. This was discussed with the attending and the patient was stable and cleared for discharge. She was to follow up with her private OB/GYN for prenatal care. The patient was given appropriate precautions to return if there are any changes in her status. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

Based upon review of the medical records in this case, the presentation of the patient, and the Milliman Care Guidelines (MCG) Care guideline entitled "Obstetric and Gynecologic Disease General Recovery Guidelines (GRG), there would be no medical necessity for acute inpatient level of care admission given fever in pregnancy with upper respiratory infection.
In this case, the patient was noted to have a reassuring fetal heart rate tracing. There was no hemodynamic instability and the patient had normal vital signs for pregnancy. Specifically, pregnancy is associated with lower systolic and diastolic blood pressure as well as tachycardia in 20-30% of patients. The patient had no evidence of fetal compromise. There was no evidence of obstetric infection to include chorioamnionitis, endometritis, or pelvic abscess. There is no peritonitis or septic pelvic thrombophlebitis present. There was no pregnancy losses case and there was reassuring fetal testing. The patient was noted to have no significant heart failure, pulmonary disease, or comorbid condition such as peripartum cardiomyopathy present. There was no uterine bleeding noted. Based upon these findings, the patient would not require acute inpatient hospitalization and could have been managed at a lower level of care status.
Under a lower level of care status, the patient could receive antibiotics for infection via oral or parenteral manner given she had a sick contact with an upper respiratory infection. The patient had a normal chest x-ray and a negative rapid flu test. There was no evidence of suspected fetal compromise. There was a normal arterial blood gas noted in this case. Respiratory alkalosis is a normal result of pregnancy. The patient's fever resolved on antimicrobials and she was discharged to home with antibiotics. Specific to this case, the patient did not have fetal compromise, hemodynamic instability or obstetric infection that would require inpatient level of care. The patient had an upper respiratory tract infection with negative influenza swab. She was treated with azithromycin and DuoNebs. She was discharged to home with resolved symptoms on hospital day 1. There would have been no medical necessity for admission to acute inpatient level of care.