Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological-miscarriage/spontaneous abortion
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan determination.

This patient was transferred from an outside hospital for further evaluation of vaginal bleeding. The patient has a prior history of trachelectomy and had a permanent abdominal cerclage in place. The patient had vaginal bleeding for several days. She had a prior history of 2 cesarean deliveries  in the past. There is also mention of two prior vaginal deliveries involving intrauterine fetal death of twins at 36 weeks. The patient had a white blood cell blood cell count of 18 and an hCG of 20,987. Urine white blood cells were also positive. A bedside ultrasound noted a thickened endometrium with 5 cm diameter.  A diagnosis of incomplete abortion was assigned. The patient was evaluated by the gynecology team and the patient was for dilation and curettage. The patient was started on clindamycin by intravenous and given Tab misoprostol 1000 mg. 
The operative notes documented a 12 week size uterus with products of conception at the cervical os. This was removed and the patient was noted to be dilated to 2 cm. She was given paracervical vasopressin followed by IV oxytocin in the operating room. There were no complications of surgery noted. The postop hemoglobin was 7.8 with hematocrit 23.5%. The patient underwent a placement of Nexplanon contraceptive implant the next day. The patient was treated for endometritis. She was discharged to home with follow-up in the outpatient setting. 
Based upon a review of the presentation of incomplete abortion in the first trimester, there would not have been medical necessity for admission to acute inpatient level of care. In this case the patient underwent an uncomplicated dilation and curettage. She had blood loss from the experience, but her hemoglobin and hematocrit were stable on two assessments post-op. She was treated for possible endometritis. Vital signs were stable throughout the hospitalization.
The procedure of D&C is usually performed as an outpatient procedure. Accepted treatment options for early pregnancy loss include expectant management, medical treatment, or surgical evacuation.
In this case, given the bleeding, surgical intervention was the appropriate intervention, and a D&C was completed. Surgical uterine evacuation has long been the traditional approach for women presenting with early pregnancy loss and retained tissue. Women who present with hemorrhage, hemodynamic instability, or signs of infection should be treated urgently with surgical uterine evacuation. Surgical evacuation also might be preferable in other situations, including the presence of medical comorbidities such as severe anemia, bleeding disorders, or cardiovascular disease. Many women prefer surgical evacuation to expectant or medical treatment because it provides more immediate completion of the process with less follow-up. In the past, uterine evacuation often was performed with sharp curettage alone. However, studies show that the use of suction curettage is superior to the use of sharp curettage alone. Suction curettage also can be performed in an office setting with an electric vacuum source or manual vacuum aspirator, under local anesthesia with or without the addition of sedation. Surgical management in the office setting offers significant cost savings compared with the same procedure performed in the operating room. Thus, based upon the recommendations of American College of Obstetricians and Gynecologists (ACOG), surgical D&C can be performed in the office setting and does not require acute inpatient level of care. However, given this patient's bleeding and infection considerations in this case, the appropriate level of care would be hospitalization at a lower level of care. There would have been no indication for admission to acute inpatient level of care.