Appeal type: Medical necessity
Decision: Overturned

The patient is a gravida (G)2, para (P)1 001 at 29 1/7 weeks, singleton gestation, who was brought in by Emergency Medical Services (EMS)  due to complaints of multiple episodes of nausea / vomiting (6 times an hour), chills, contractions, and abdominal pain.
Her obstetrical history was significant for 1 normal spontaneous vaginal delivery (NSVD). Her medical history was significant for anemia.
On initial evaluation the patient was afebrile with stable vital signs. Her pain score was 5/10. On electronic fetal monitoring contractions every 3 minutes were noted. Cervical examination was 1 / 60%/-2 with change to 2/60%/-1.
Laboratory work-up demonstrated elevated white blood cell (WBC) count with left shift: 13.7; neutrophils were 91.8%; hemoconcentration with hemoglobin and hematocrit 13.6 and 42.2, respectively; normal electrolytes and liver function tests (LFTs); negative urinalysis.
The overall impression was gastroenteritis and preterm contractions / rule out preterm labor.
The patient was admitted to labor and delivery, started on magnesium sulfate tocolysis, received intravenous (IV) antibiotic prophylaxis for group B streptococcus (GBS); steroids for fetal lung maturity, IV hydration and IV Zofran.
The patient complained of loss of fluid per vagina; on sterile speculum examination no pooling was noted; cottage cheese - like discharge was noted; cervical length was 1.4cm; pre-term premature rupture of membranes (PPROM) was ruled out.
Contractions gradually resolved. There was no further cervical dilatation. Abdominal pain and nausea/vomiting resolved.
The patient was seen by a maternal fetal medicine (MFM) consultant. Official ultrasound was performed: estimated fetal weight (EFW) was 1542g; cervical length was 1.7 cm. The patient was discharged home.

The health plan's determination is overturned.

Yes, the requested Inpatient stay was medically necessary for this patient. Based on provided clinical information, the patient presented with clinical signs and symptoms of infection / inflammation (elevated WBC to 13.7 and left shift - neutrophil percentage was 91.8%), dehydration (manifested by hemoconcentration with hemoglobin and hematocrit of 13.6 and 42.2, respectively), as well as preterm labor - progressive cervical dilatation: Cervical examination was 1 / 60%/-2 with change to 2/60%/-1.
The standard management of preterm labor (with or without coexistent infection/inflammation) is continuous fetal monitoring, administration of tocolytics ( such as magnesium sulfate ), steroids for fetal lung maturity, and antibiotics. All of the above was performed.
Magnesium sulfate administration and continuous prolonged fetal monitoring require inpatient level of care and cannot be accomplished at a lower level of care status.
As the patient completed magnesium sulfate tocolysis, she was evaluated by an MFM physician, ultrasound examination was performed, and the patient was discharged as her symptoms resolved.
Therefore, the entire management of the patient as inpatient, was consistent with available literature evidence, generally accepted standards of practice and, therefore, was medically necessary with respect to type and extent of intervention.