Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Miscarriage at 9 Weeks' Gestation, Vaginal Bleeding, Nausea and Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female who arrived to the emergency department (ED) with complaints nausea and vomiting. She was noted to have a hemoglobin of 13.4 with a hematocrit of 38.5 percent (%). The patient underwent a transvaginal ultrasound which demonstrated a single intrauterine gestation with a gestational age of 10 weeks and four days with a heart rate of 179 beats per minute (bpm). Ovaries were normal in size with a right sided corpus luteum cyst. The uterus was noted to be normal. There was no free fluid appreciated. A viable intrauterine pregnancy was noted. The patient was approximately nine weeks pregnant. The patient started to have vaginal bleeding on the day of presentation with the passage of clots and possible products of conception. The patient reported two syncopal episodes at home. She reported suprapubic pain and hyperemesis. The physical examination was noted to be normal. The genitourinary examination noted no lacerations in the vaginal vault and blood was falling into the speculum with dark blood and no tissue appreciated. The patient was planned for ongoing intravenous (IV) fluids. She had no signs of distress per documentation. She reminded alert and oriented. An electrocardiogram (EKG) was performed and normal with a normal sinus rate of 69 bpm. She was given IV thiamine. Her initial potassium of 2.9 was improved with IV fluids to 3.3. She had repeat liver function tests which were improved. She was admitted to the Gynecological service. She had no abnormal vaginal discharge. She had a normal examination with 5 cubic centimeters of blood in the vaginal vault. She had a normal cervix. There was 3 centimeters of rubbery tissue removed from the os. The uterus was mobile and slightly tender. She was started on Pepcid, Reglan, and B6 which improved her nausea and vomiting. Renal function remained normal. She remained afebrile and with stable vitals for the remainder of the admission. 

At issue is the medical necessity for an inpatient hospital admission.
I uphold (in whole) the health plan's determination of medical necessity.

The acute inpatient admission is not medically necessary.

The patient was noted to be medically stable and without any serious comorbidities. She had normal vital signs. The patient also was able to tolerate some oral intake. The patient's admission to an acute inpatient level of care was not medically necessary as she did not have any findings of hemodynamic instability, vomiting that was severe or persistent, dehydration that was severe or persistent, severe electrolyte abnormalities, a metabolic disorder that was severe or persistent, abdominal pain, significantly elevated serum transaminases, significantly elevated bilirubin, significantly elevated serum amylase or lipase, coagulopathy, ascites, acute renal failure, significant neurologic finding, fetal compromise, or hydatidiform mole complicating pregnancy. The patient's care could have been performed at an alternate level of care with imaging, antiemetic therapy, potassium replacement, IV hydration, and nutritional and pharmacologic management. Based upon the recommendations of the American College of Obstetrics and Gynecology (ACOG), an inpatient admission was not medically necessary.

The patient was also noted to have excessive vaginal bleeding with a viable intrauterine pregnancy. There was no indication that the patient was coagulopathic or unstable. Thus, an ultrasound was performed and was reassuring. There would have been no indication for admission to an acute inpatient level of care for threatened abortion based upon the patient's stable status and viable intrauterine pregnancy. This care could have been performed at an alternate level of care.