Appeal type: Medical necessity
Decision: Upheld

Gynecological
Inpatient Hospital

The patient is a female gravida (G)1 para (P)0 who presented at 22-3/7 weeks gestation  for cerclage placement due to cervical length of 0.69 centimeter (cm) with funneling noted. The patient previously had a diagnosis of short cervix 2 weeks prior with a 2.41 cm and was started on vaginal progesterone at that time. The patient denied contractions, leakage of fluid, vaginal bleeding and endorsed occasional fetal movements. The prenatal course was noted for short cervix diagnosed 2 weeks prior on vaginal progesterone. The patient also had a normal anatomy scan and normal genetic screening. The patient had a previous history of toxoplasma in the right eye and had been evaluated. She also had CT exposure in pregnancy and a history of urinary tract infections during the pregnancy. The patient had no past medical or surgical history otherwise. The patient was a nonsmoker and does not use alcohol. The patient reported allergy to penicillin which causes hypotension. The patient's medications included a prenatal vitamin and vaginal progesterone 200 milligrams (mg) given vaginally at bedtime.

The patient was taken to the operating room where she underwent an emergency cerclage with amnio reduction. A cervical cerclage 2 was placed with exam under anesthesia performed. Spinal anesthesia was used and there was no specimen sent. The procedure was completed without difficulty and the total estimated blood loss was 25 milliliter (mL). The patient received a 1-0 Prolene cerclage placement. The patient was taken to the recovery room in stable condition.

Following the procedure, the patient was postop day 1 status post rescue cerclage. She remained stable with a temperature 98.3F and heart rate of 97. Respiratory rate was 18 with an oxygenation 99% on room air. The blood pressure was 118/71. The patient was on indomethacin 25 mg every 6 hours. She was on a regular diet and on oxygen therapy. The patient was stated not feel well enough to go home at that time and the patient was allowed to stay in the hospital due to a lot of cramping. The plan was to allow the patient to stay for the rest of the night. There were no additional interventions or orders given as a result of this change. The patient was discharged home. Appropriate follow-up was scheduled in the outpatient setting. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

In this case, the patient was preterm, periviable with a plan of placement of cerclage due to possible incompetent cervix. The patient had a short cervix noted. She was planned for McDonald cerclage. There was no evidence of preterm labor and the cerclage was placed without difficulty. The cervix was closed at the time of placement and there was a reassuring post-operative cervical length. In this case, the standard of care would be weekly monitoring for preterm labor and cervical exam.
The acute inpatient antepartum level of care would not be medically necessary in this case in a patient without any acute status for preterm labor or delivery. Admission to acute inpatient care would have been deemed medically necessary under the Milliman Care Guidelines (MCG) Care Guideline "Preterm Labor, Threatened" for the following:
	Condition requiring premature delivery (e.g., preterm premature rupture of membranes with nonreassuring fetal status, chorioamnionitis) - this was not present
	Preterm rupture of membranes- this was not present
	Fetal distress or demise- this was not present
	Significant maternal disease - this was not present. She had hypertension that was well controlled.
	Significant vaginal bleeding or vaginal bleeding with known placenta previa, vasa previa, or placenta accreta - this was not present
	Complications of tocolytic therapy - this was not present and was not indicated.
	Inpatient admission required for continued fetal monitoring that requires inpatient care, tocolytic therapy needed that requires inpatient care, Inability to stop preterm labor - None of these are present. There was no need for ongoing tocolysis as the patient was quiescent without any progress toward labor or delivery. There was oral Indocin administered as a plan for cerclage.

The performance of the cerclage in this case would not be medically necessary at an inpatient level of care and would be appropriate for a lower level of care status.