Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out Preterm Labor.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay. The determination is upheld.

The patient is a gravida (G) 3 para (P) 1102 who was at 28-0/7 weeks gestational age. She was admitted to rule out preterm labor.

The patient presented with sharp abdominal pain that began the prior night. She reported that the pain comes on randomly as irregular. She reported that the pain lasts for 15-20 minutes and when it occurs, it resolves on its own. She denies leaking of fluid, vaginal bleeding and endorses normal fetal movement. She denies recent trauma or symptoms of infection. She denies abnormal vaginal discharge. She does not drink a lot of water at home. The patient received prenatal care. Her last prenatal note was noted only for anti-M antibodies, which were subsequently negative on repeat evaluation by the lab. The patient had a history of asthma and had used an albuterol inhaler often early in pregnancy but more recently had not needed this. She reported her pregnancy was otherwise uncomplicated. The patient had a history of 2 prior vaginal deliveries with one being preterm and both being complicated by maternal anemia. The past obstetrical history was noted for normal spontaneous vaginal delivery times () 2 with 1 delivered preterm at 36-5/7 weeks' gestation and the pelvis tested to 5 pounds (lbs) 8 ounces (oz). Her past gynecologic history was notable for regular menses and no evidence of sexual transmitted infections or abnormal Pap smears.

The past medical history was notable for asthma with her last albuterol use months earlier. She also has scoliosis. Past surgical history was denied. She had no known allergies. Her medications included prenatal vitamins. The patient denied tobacco, alcohol or drug use. The patient's body mass index was 24.41 kilograms per square meter (kg/m2). Her prenatal labs showed the blood type to be A positive (+). The review of systems was noted to be positive for abdominal pain and pelvic pain. This was otherwise negative for vaginal bleeding, dysuria, vaginal discharge, dizziness, lightheadedness, chest pain, nausea or vomiting, diarrhea, constipation, or chills or fever. The patient's prior obstetric history was noted for her first pregnancy delivery at 41 weeks gestation by vaginal delivery and her second delivery being preterm at 36 weeks and 5 days with a birth weight of 5 pounds 8.9 ounces.

Her physical examination was noted to be normal. She was in no acute distress. The lungs and heart were normal. The abdomen was soft, gravid and nontender. There was no lower extremity edema. Bedside ultrasound noted a singleton gestation in cephalic presentation with an anterior placenta and amniotic fluid index of 15 centimeters (cm). The estimated fetal weight was 1137 grams, consistent with 27 weeks and 4 days. A sterile speculum exam noted no pooling of fluid or blood seen within the vaginal vault. The fetal heart tones were in the 150s with moderate variability, positive accelerations, and no decelerations. The membrane status was intact. The cervical exam noted the patient to be 2 centimeter (cm), long, and high and this was 3 cm, 50%, and -3 station.
The patient was admitted for evaluation for possible preterm labor. She reported sharp irregular abdominal and pelvic pain that began last night but was otherwise without labor complaints. There is irritability on toco (tocodynamometry) with a few irregular contractions. Oral hydration had been given in the triage unit as well as intravenous (IV) hydration. She had had minimal cervical change after 2 hours of evaluation and maintain an intact bag of water. There was concern for possible premature cervical dilation. She was admitted to antepartum for observation and antenatal corticosteroids. The first dose of betamethasone was given in triage with a plan for a second dose in 24 hours. The fetus remained reassuring with a reactive and reassuring nonstress test. Ultrasound was also reassuring. The patient was plan for official maternal fetal ultrasound on the third day if she remained in the hospital at that time. Overall there was reassuring fetal status. Prenatal labs were to be obtained. A neonatal consult was also ordered. The patient's group B strep status was unknown and this was collected. She was Rhesus (Rh) factor positive (+). She was also to have sequential compression devices to exclude risk for clot but heparin was to be held given the possibility of preterm labor.

The patient received her first dose of betamethasone. She was also started on magnesium sulfate at 2 grams per hour. The patient was continued on penicillin G for Group B Streptococcus (strep) unknown status and possible preterm labor. The patient was seen in consult by neonatology during the hospitalization and counseled on expectations of delivery at this gestational age.

The patient was noted to have no acute events overnight. She had 1 episode of abdominal pain that lasted for seconds. She denied vaginal bleeding or leakage of fluid. The patient reported good fetal movement. She had a heart rate of 98 and respiratory rate of 18. She was afebrile at 98.1 degrees Fahrenheit (F) with 100% oxygenation on room air. The patient had a normal physical exam with a soft, gravid and nontender abdomen. The patient had been noted for irregular contractions during triage and her cervix had remained unchanged overnight with this morning the cervix being 3, 50% and -3 station. There had been no change in fetal status. The plan was made to continue observation antepartum to complete antenatal corticosteroids. Fetal testing remained reassuring and the patient had group B strep testing that had been collected and was pending. The patient had a complaint of abdominal tightness and was placed on the monitor. She was noted to be stable without any significant change. The cervical exam remained reassuring. The patient was noted to have some variable decelerations at that time with this episodic pain. She was taken to labor and delivery where she was monitored and noted to have category 1 fetal testing with a baseline in the 140s with moderate variability, positive accelerations and negative decelerations. Contractions were noted every 5 minutes. The vaginal exam was unchanged at 3 cm, 50% effaced and -2 station. Membranes were intact and the placenta was anterior. The fetus was in a cephalic presentation. Fetal monitoring remained category 1 or category 2 with variable decelerations with baseline moderate variability. The patient then regained category 1, testing was reassuring without decelerations. Group B strep testing was noted to be negative. The patient was comfortable and was now placed on indomethacin for tocolysis. Contractions had spaced out to every 20 minutes. The patient remained with a category 1 fetal monitoring strip. She was receiving indomethacin 25 milligrams (mg) every 6 hours and magnesium maintenance of 2 g per hour with penicillin every 4 hours. The patient remained without any complications of tocolysis. Her cervical exam remained stable at 3, 50% and -3 station. There was no significant change in cervical examination. The patient was continued on magnesium sulfate for fetal neuroprotection. The patient completed 12 hours of magnesium, indomethacin tocolysis and penicillin. The magnesium was stopped at that time and there was a plan made to transfer the patient to the antepartum unit and continue indomethacin until the antenatal corticosteroid course was completed. The patient remained comfortable at that time.

The patient reported feeling comfortable and had no contractions. She reported good fetal movement and denied vaginal bleeding or leakage of fluid. Blood pressure was 104/65 with a heart rate of 105 and temperature 98.3F. The patient had oxygenation of 100% on room air. Fetal testing was category 1 and reassuring. The cervical exam was unchanged at 3 cm, 50% effaced and -3 station. The patient was admitted for preterm labor and was now 28-2/7 weeks gestational age. The patient was to continue albuterol and Singulair as needed and to avoid Hemabate and labetalol given her asthma. The patient had preterm contractions and was now comfortable. Her cervical exam was unchanged. She was status post indomethacin for tocolysis and denied any contractions at that time. She had no labor complaints. The patient was stable and without evidence of any continuing preterm labor. She was transferred to antepartum for further monitoring. The baby was vertex with an estimated fetal weight of 1137 grams and was status post a second dose of corticosteroids and magnesium for neuroprotection. The plan was made for artificial growth ultrasound at that time. She was to continue on a daily nonstress test. Given that the patient had no ongoing preterm labor and had completed magnesium and steroids with Indocin for tocolysis, a plan was made for discharge to home with outpatient follow-up.

At issue is the medical necessity of an inpatient stay.

The care as rendered for the patient with threatened preterm labor would not have required admission to the acute inpatient level of care. The care as provided for management of threatened preterm labor would be appropriate at a lower level of care, given the lack of need for delivery or moving to delivery. In this case, the patient was noted to have minimal cervical change and would be indicated for magnesium for neuroprotection and antenatal corticosteroids. Given some breakthrough contractions and variable decelerations, she was augmented with Indocin orally for tocolysis. She completed the appropriate duration of magnesium for neuroprotection and tocolysis to achieve completion of corticosteroids. The American College of Obstetrics and Gynecology makes the following recommendations for the management of threatened preterm labor: 1) A single course of corticosteroids is recommended for pregnant women between 24 weeks and 34 weeks of gestation, who are at risk of preterm delivery within 7 days. -This was performed in this case as was indicated; 2) Accumulated available evidence suggests that magnesium sulfate reduces the severity and risk of cerebral palsy in surviving infants if administered when birth is anticipated before 32 weeks of gestation. Hospitals that elect to use magnesium sulfate for fetal neuroprotection should develop uniform and specific guidelines for their departments regarding inclusion criteria, treatment regimens, concurrent tocolysis, and monitoring in accordance with one of the larger trials.- this was performed in this case as was appropriate; 3) The evidence supports the use of first-line tocolytic treatment with beta-adrenergic agonist therapy, calcium channel blockers, or nonsteroidal anti-inflammatory drugs (NSAIDs) for short-term prolongation of pregnancy (up to 48 hours) to allow for the administration of antenatal steroids. This was performed in this case and was appropriate to achieve completion of corticosteroids; 4) Maintenance therapy with tocolytics is ineffective for preventing preterm birth and improving neonatal outcomes and is not recommended for this purpose - this was avoided in this case as is appropriate for management of this patient; and 5) Antibiotics should not be used to prolong gestation or improve outcomes -This was not utilized as was appropriate. The patient was indicated for penicillin given group B strep unknown status, and that was carried out as appropriate.

In this case, there was no need for admission to inpatient care for this care to be provided in the form of magnesium for neuroprotection, oral Indocin for tocolysis, penicillin for group B strep coverage and monitoring. In this case, there was no delivery or indication for delivery which would have moved the care to be medically necessary at the acute inpatient level of care by the American College of Obstetricians and Gynecologists (ACOG) and peer reviewed literature. The care provided was as recommended by national standards of ACOG and could have been completed at a lower level of care.