Appeal type: Medical necessity
Decision: Upheld

Diagnosis: 40 Weeks Gestation, Induced Labor.
Treatment: Inpatient Stay.
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient is a female who was at 39-5/7 weeks gestation who presented for induction of labor due to advanced maternal age (AMA). The pregnancy was complicated by AMA and Class III obesity. She was Group B Streptococcus (GBS) negative. The patient was admitted to the hospital for the induction. There was no other medical or surgical history noted. She was a non-smoker and did not use alcohol. The patient had a blood pressure of 137/74 and her heart rate was 80.

The examination noted the estimate of fetal weight to be 7 pounds (lbs.) 2 ounces (oz). The estimated fetal weight (EFW) was limited by maternal body habits. The cervix was 2 centimeter (cm) dilated/thick and minus (-)3 station. There was a vertex presentation on ultrasound and anterior placenta. The amniotic fluid volume was normal by deep vertical pocket of 4.63 cm. The patient was admitted and a Cervidil insert was placed for pharmacologic induction of labor. Upon completion of 12 hours of Cervidil, the cervix was now 3 cm dilated and the patient underwent Pitocin by intravenous (IV) titration for induction of labor. She had no cervical change on this medication and Cytotec was then administered 25 micrograms (mcg) orally every (q) 2 hours. This resulted in a cervical change to 4 cm with a thick cervix remaining. The head was ballotable. The patient was given options for discharge to home at that time verses a primary cesarean delivery. She opted to be discharged to home undelivered. Labor precautions were provided and the patient was discharged to home. The fetal status was reported as reassuring. A plan was made to schedule her for a new induction of labor date.

Based upon this care, the recommendations by the American College of Obstetrics and Gynecology and the Milliman Care Guidelines (MCG) Health General Recovery Care 26th Edition guideline entitled "Obstetric and Gynecologic Disease General Recovery Guidelines (GRG)", there would have been no medical necessity for admission to an acute inpatient level of care for a failed induction of labor with a reassuring fetal and maternal status. 

In this case, admission to acute inpatient level of care can be indicated for the following:

1)Fetal compromise - this was not present
2)Hemodynamic instability - this was not present
3)Obstetric infection - this was not present
4)Pregnancy loss - this was not present
5)Uterine bleeding with high-risk features - this was not present
6)Placenta previa - this was not present
7)Vaginal delivery or cesarean delivery - this was not present as the induction was canceled.
The care provided for cervical ripening, fetal monitoring and maternal monitoring would be at an alternate level of care in the absence of delivery by vaginal birth or cesarean as presented in this case.

The American College of Obstetrics and Gynecology Practice Bulletin on Labor Induction states the following:

What are the indications and contraindications to induction of labor?

Indications for induction of labor are not absolute but should take into account maternal and fetal conditions, gestational age, cervical status, and other factors. Following are examples of maternal or fetal conditions that may be indications for induction of labor:
Abruptio placentae
Chorioamnionitis
Fetal demise
Gestational hypertension
Preeclampsia, eclampsia
Premature rupture of membranes
Post term pregnancy
Maternal medical conditions (e.g., diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)
Fetal compromise (e.g., severe fetal growth restriction, isoimmunization, oligohydramnios).