Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is upheld in whole.

The patient is a gravida (G)2 para (P)1 female who presented at 30 3/7 weeks gestation by first trimester ultrasound consistent with last menstrual period (LMP) in a pregnancy complicated by preterm contractions with a diamniotic, monochorionic twin gestation. The patient had a prior history of cesarean and hypothyroidism. She presented with complaints of contractions. At presentation, the patient had normal vital signs and was afebrile at 98.2 Fahrenheit (F). She had normal blood pressure and pulse. Oxygenation on room air was normal. Fetal testing was reassuring for both twins and Category I. There were contractions noted every 10 minutes. Cervical exam was 1/90% effaced and -2 station. Trans-perineal scan was reported to be similar to pelvic exam. Both a complete blood count and complete metabolic panel were normal. The patient was admitted at 30 3/7 weeks for preterm labor management. She had reassuring fetal status and was consented for cesarean if labor occurred. She was to receive magnesium for neuroprotection and tocolysis. She also was to receive a course of steroids. The first dose had been given at admission. The patient was 30-2/7 weeks and had a concern for leaking a small amount fluid. This was not persistent, and she still had painful contractions. There was no vaginal bleeding and good fetal movement was noted. The patient was noted to be group B strep positive by bacteriuria. Examination by ultrasound noted vertex-vertex presentation with an estimated fetal weight of 1188 grams (g) and 1227 g. Fetal heart tones remained reassuring in category 1. The patient had reassuring fetal testing and plan was made for possible discharge to home on the following day if she remained stable. The patient was transferred to antepartum given her stable examination and lack of contractions. The patient had completed steroids. Cervical exam had remained unchanged. The patient was discharged home with follow-up in the outpatient setting. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination of medical necessity is upheld in whole.

Based upon a review of the medical records, the recommendations of the American College of Obstetrics and Gynecology (ACOG) and the Milliman Care Guidelines (MCG) Guideline entitled "Preterm Labor, Threatened, there would have been no medical necessity for acute inpatient level of care admission. In this case, the patient was noted to have a twin gestation at 30 weeks gestation with threatened preterm labor. There was no change in cervical exam throughout admission to document the cervix had changed in response to contractions. However, given preterm contractions, a plan was made for ultrasound, magnesium and steroids. The ultrasound and monitoring were reported as normal and reassuring with a twin gestation that was normally grown with normal fluid and testing. The patient completed a 24-hour window of magnesium sulfate without complications. There was completion of two doses of betamethasone for fetal lung maturity. The patient had a trial of tocolysis that was successful and without complications with the magnesium sulfate. In this case, the care rendered would have been appropriate at a lower level of care status.