Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligohydramnios. 
Treatment: Inpatient Hospital Stay. 

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

The patient is a gravida (G) 3 para (P) 2 who was sent to triage from her private Obstetrician/Gynecologist (OB/GYN) due to oligohydramnios. The patient reported that she drinks some juice and tea. The patient had presented for assessment.
She reported good fetal movement with no vaginal bleeding or leakage of fluid. There were no uterine contractions. She denied a headache, vision changes, chest pain, shortness of breath, abdominal pain, nausea or vomiting, leg pain or dysuria. Her antepartum course was significant for a recurrent yeast infection and she had limited prenatal care. Her past obstetrical history was noted for a term male by Cesarean delivery due to nonreassuring fetal heart tones. She then delivered a term female by repeat Cesarean and this was her third pregnancy. The patient denied any history of fibroids, cysts, or abnormal Pap smears. She had no history of sexually transmitted infections. Her past medical history was negative. Her past surgical history was noted for Cesarean section times () 2. Her psychiatric history was notable for reports of a history of postpartum blues. Her medications included prenatal vitamins. Her social history was negative for smoking, alcohol or illicit drug use. She had no known drug allergies. 
At presentation, her blood pressure was 118/74 with a heart rate of 88 and respiratory rate of 18. Her temperature was 98.2 degrees Fahrenheit (F) with an oxygen saturation of 99% on room air. Her exam revealed a soft abdomen that was nontender with a gravid uterus without suprapubic tenderness. There was no guarding and no rigidity. The patient had no costovertebral angle tenderness. Her lower extremities were symmetrical and nontender bilaterally without calf tenderness. She had a negative Homan's exam. The patient's pelvic exam noted no lesions or abnormalities on the external genitalia, vulva, vagina or cervix. The cervix was closed, long and posterior. Electronic fetal monitoring noted 150s with moderate variability and positive accelerations with no decelerations. It was category 1 and reassuring. There were no regular uterine contractions. A bedside ultrasound noted an amniotic fluid index (AFI) of 6.89 centimeters (cm) with the deepest vertical pocket of 1.86 cm and estimated fetal weight of 2807 grams (g) with an anterior placenta and cephalic presentation.
The patient had labs evaluated which noted a white blood cell count that was normal at 9.79 with a hemoglobin of 12.1 and hematocrit 35.8%. The platelet count was 240. A complete metabolic panel was normal and coagulation testing was also normal. The patient had a urinalysis that was also reassuring. The patient was admitted at 36-3/7 weeks for a low amniotic fluid index with a reassuring category 1 tracing and was noted to have a bedside ultrasound with normal AFI of 6.9 cm and an Amnisure (PAMG-1) test that was negative for ruptured membranes. The patient was admitted for prolonged monitoring and had a group B strep collected. They also collected for gonorrhea and chlamydia panel and vaginitis panel. Intravenous (IV) fluids were started and the patient was encouraged to have oral intake. The patient was to have betamethasone for fetal lung maturity and was made nothing by mouth. An obstetric (OB) sonogram was planned and if there was ongoing oligohydramnios a consideration for repeat Cesarean section would be planned at that time. 
The patient was doing well and had no current complaints. She no headache, vision change or shortness of breath. She reported no chest pain, leg pain or abdominal pain. The patient had completed betamethasone for fetal lung maturity. The blood pressure was normal at 128/71 with a heart rate of 91. Electronic fetal monitoring noted a heart rate in the 135 range with moderate variability, positive accelerations, and no decelerations. This was category 1 and reassuring. There were no contractions noted. The abdomen noted no abdominal tenderness and no guarding or rigidity. The patient was now at 36-3/7 weeks admitted for observation secondary to decreased amniotic fluid index with no fluid, vaginal bleeding or abdominal pain. Nausea, vomiting, fever and chills were negative and there was good fetal movement. An official ultrasound was planned and continued monitoring for labor as well as electronic fetal monitoring and toco monitoring were planned. The patient was to be made nothing by mouth per that note. The patient had completed betamethasone. She had been nothing by mouth and there was a plan after the official ultrasound to possibly repeat her Cesarean. 
The patient underwent a maternal-fetal medicine consultation which noted the amniotic fluid index had increased to 7.41 centimeters (cm) after IV hydration and bed rest. All other fetal testing parameters on fetal growth were also reassuring at that time with a biophysical profile that was 8 of 8 with the deepest vertical pocket 2.6 cm in vertex presentation and the umbilical artery Doppler was also within normal range. The patient was counseled on the options of a repeat Cesarean delivery on that day and the complications to be anticipated with a 36 week delivery. After discussion the patient desired to have a term delivery and was discharged to home with follow-up in the outpatient setting. She declined a Cesarean delivery at that time and opted in favor of repeat testing. The patient was discharged with follow-up in the outpatient setting.
During this hospitalization, the patient had negative group B strep culture and negative gonorrhea and chlamydia cultures as well. Fetal testing was reassuring throughout the hospitalization and AFI remained above 5 cm (the normal lower limit) on all assessments.
At issue is the medical necessity of an inpatient stay. 

Based upon a review of the medical records in this case, the peer reviewed literature, American College of Obstetricians and Gynecologists (ACOG) guidelines and recommendations, admission to inpatient emergency / acute inpatient level of care for oligohydramnios was not medically necessary. The patient was sent from her provider's office for oligohydramnios with a normal AFI value noted in the outpatient setting and in the inpatient setting. Rupture of membranes was excluded by normal exam and normal Amniosure (PAMG-1) testing. There was reassuring fetal monitoring with a Category I non-stress test with no decelerations. This was noted to persist for the entire admission period with reassuring testing and normal amniotic fluid index. Given the possible indication for early delivery, the patient was administered steroids as are recommended by ACOG and the peer reviewed literature for fetal benefit. Based upon this presentation, there would not have been a need for admission to acute inpatient level of care given reassuring fetal status, normal AFI value, and absent labor or indication for delivery. The administration of steroids, fluids, and monitoring can be performed at a lower level of care and would not have met medical necessity for inpatient emergency admission in this case. ACOG recommends that outpatient monitoring can be implemented for Oligohydramnios (AFI less than [<] 5 cm) with once or twice per week testing in the ambulatory setting. If this is seen in concert with poor fetal growth, delivery may be indicated. In this case, the AFI remained normal and there was no poor fetal growth. Thus, there would have been no indication for admission to acute inpatient level of care. There was also no labor or indication for delivery.