Appeal type: Medical necessity
Decision: Upheld

Pregnancy/Childbirth
Inpatient Hospital

Diagnosis: Pregnancy, Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay as not medically necessary.
The determination is upheld.

The patient present with abdominal pain. She had a prior history of preterm delivery and was managed on Makena injections weekly. She also had a prior history of an appendectomy in this pregnancy at 6 weeks gestation, which was performed as an open procedure. The patient reported abdominal pain and noted abdominal cramping. 
The patient had no cervical dilation or effacement. She had a -3 station at presentation. She had a prior ultrasound that had noted normal fetal growth. Vital signs were normal. The exam was normal. Fetal heart tones were reassuring. A plan was made for nothing by mouth status and she was started on intravenous (IV) fluids with a consultation by anesthesia and fetal monitoring. The plan was made for a celestone course and IV magnesium sulfate due to preterm contractions. The cervix remained closed at admission.  The patient was seen by Neonatology given prematurity.
The patient tolerated magnesium and had Category I and reassuring fetal monitoring strips. A cervical length was normal. Urine testing was negative. Preterm labor was not diagnosed as there was no cervical change.
The patient remained stable and completed dose 1 of her steroid course. She tolerated magnesium. 
She completed Celestine and magnesium and remained stable. The second dose of steroids was completed.
The patient was noted to have no contractions, bleeding, leakage of fluid and reported good fetal moment. She had a prior prolonged deceleration that required further monitoring on the prior day and was stable at that time. She was discharged to home.
At issue is the medical necessity of an inpatient stay. 

Based upon a review of the medical records, the recommendations of the American College of Obstetrics and Gynecology (ACOG) and the MCG Guideline entitled "Preterm Labor, Threatened, there was no medical necessity for acute inpatient level of care admission. The patient was noted to have a singleton gestation with threatened preterm labor. There was a closed cervical exam on admission by the physician. There was also a long and closed cervix with a normal cervical length by transvaginal ultrasound at admission. However, given preterm contractions, a plan was made for an ultrasound, magnesium, and steroids. The ultrasound and monitoring were reported as normal and reassuring. The patient completed the 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.
The patient was admitted preterm with threatened preterm labor without documented cervical change in the setting of contractions. There was no evidence of preterm labor. Standard of care would be observation for cervical change. Preterm labor was not present as there was no cervical change documented by the physician.  ACOG states the following regarding this practice: "Tocolytic therapy may provide short-term prolongation of pregnancy, enabling the administration of antenatal corticosteroids and magnesium sulfate for neuroprotection, as well as transport, if indicated, to a tertiary facility. However, no evidence exists that tocolytic therapy has any direct favorable effect on neonatal outcomes or that any prolongation of pregnancy afforded by tocolytics  translates into statistically significant neonatal benefit." Care could have been provided at a lower level.