Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm labor.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is gravida (G) 5 para (P) 30132 who presented at 34-1/7 weeks' gestation as dated by a 20 week ultrasound with complaints of preterm labor. The patient did not know how often her contractions were at presentation. She denied leakage of fluid, vaginal bleeding and endorsed good fetal movement. The patient had not established prenatal care. Her pregnancy was complicated by influenza with superimposed pneumonia but currently denied symptoms.
She also had hypothyroidism, managed on Synthroid 50 micrograms (g) daily, and known group B streptococcus (GBS) bacteriuria. The patient's review of systems was noted to be negative for fever, shortness of breath, chest pain or palpitations. She had no nausea or vomiting. She was negative for dizziness or dysuria. Her prior obstetric history was noted for 3 prior term deliveries. Her largest was 6 pounds. She had 1 prior ectopic pregnancy with a left salpingectomy as a result. Her gynecologic history was negative for sexually transmitted infections. Her past medical history was noted for hypothyroidism. Her past surgical history was noted for a salpingectomy. She had no prior history of blood transfusions. She was a nonsmoker and did not use alcohol. She lives at home with her husband and children. Her medications include levothyroxine 50 g orally daily with a prenatal vitamin. She reported no known allergies. Her last menstrual period was reported is mid 2019. Her examination was normal with a gravid abdomen that was nontender but with palpable contractions. A sterile speculum exam was deferred. The cervix was checked and found to be 3 centimeters (cm), 50% effaced, and -3 station. Fetal testing was reassuring and category 1 with contractions every 2-3 minutes noted. An ultrasound was performed which showed a singleton intrauterine pregnancy in a cephalic presentation with posterior placenta. The estimated fetal weight was 2485 grams (g) by ultrasound at the 61st percentile. A thyroid stimulating hormone (TSH) was noted to be normal at 1.74 demonstrating well controlled hypothyroidism. The patient had received influenza and TDaP (tetanus, diphtheria, and pertussis) vaccination.
The patient was admitted with a diagnosis of preterm labor at 34-1/7 weeks' gestation with known hypothyroidism, well controlled on levothyroxine and a history of GBS bacteriuria with reassuring maternal and fetal status. The patient was admitted to labor and delivery and informed consent was obtained. Routine labs were sent. She was made nothing by mouth with ice chips. She was started with penicillin and intravenous (IV) access and a betamethasone course was ordered. An maternal fetal medicine (MFM) consult was ordered and a glucose tolerance test was also ordered. Continuous monitoring was planned at that time. The patient was seen by maternal fetal medicine which found her vital signs to be stable and afebrile. The patient was recommended for admission with dexamethasone for fetal lung maturity and penicillin for the group B strep positive status. The patient was also started on magnesium at that time.
The magnesium was discontinued and the penicillin G was continued. The patient was to receive her second dose of betamethasone that afternoon. She was planned for continuing monitoring overnight and discharged in the morning if she remained stable. The patient was also seen by maternal fetal medicine and was feeling well with no complaints. She had no chest pain, shortness of breath, or palpitations. She had no abdominal pain. She denied headache or dizziness. She denied vaginal bleeding, leakage of fluid or other problems. She reported good fetal movement. She remained afebrile. Fetal status remained reassuring and category 1. Her cervical exam remained stable at 3 cm, 50% effacement and -3 station. There had been no change since admission. Her blood type was A positive (+) with a negative antibody screen. The patient had a normal white blood cell count 7.1 with a hemoglobin of 10.7 and hematocrit 31.8. The platelets were normal at 242. A urinalysis was noted to be normal. The patient's rapid plasma reagin (RPR) was nonreactive. The patient was continued on the current management plan with follow up on cultures. Betamethasone dose #2 was planned at 16:45 and magnesium sulfate was continued for tocolysis. The patient was on Synthroid daily. Follow-up cultures were pending and the patient remained stable.
The patient remained afebrile with stable vital signs. Her abdomen was soft nontender and nondistended. The patient was discharged home with preterm labor precautions and fetal movement counts daily basis. She was given appropriate precautions for follow-up. She also had a nonstress test completed that was reassuring and category 1 prior to discharge. 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 Milliman Care Guidelines (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 at 34 1/7 weeks gestation with threatened preterm labor. There was cervical dilation on admission that was 3 cm/50% but no demonstrated cervical change as this remained stable over serial exams. Contractions were present on presentation with reassuring fetal status. However, given the preterm contractions, a plan was made for ultrasound, magnesium and steroids despite the patient being beyond 34 weeks gestation. The ultrasound and monitoring were reported as normal and reassuring with a singleton gestation that was normally grown with normal fluid. The patient completed a 36 hour window of magnesium sulfate without complications. There was the 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 the observation level of care. In this case, the MCG Care Guideline entitled "Preterm Labor, Threatened" would support admission to acute inpatient level of care for the following:
1)	Condition requiring premature delivery (eg, preterm premature rupture of membranes with nonreassuring fetal status, chorioamnionitis - This was not present in this case.
2)	Fetal distress or demise - This was not present and the fetal status was reassuring.
3)	Preterm prelabor rupture of membranes - This was not present.
4)	Significant maternal disease (eg, infection) identified (eg, pyelonephritis, pneumonia) that requires inpatient treatment (eg, IV antibiotics, close monitoring) - This was not present as the patient had no medical conditions other than well controlled hypothyroidism.
5)	Vaginal bleeding (eg, placental previa, vasa previa, placenta accreta) - This was not present.
6)	Complications of tocolytic treatment (eg, pulmonary edema, hypotension) - There were no complications of tocolysis in this case.
7)	Continued fetal monitoring that requires inpatient care (ie, needed beyond observation care time frame (eg, 24 hours)) - This was not present in this case as tocolysis is not recommended by ACOG beyond 33 6/7 weeks gestation.
8)	Tocolytic therapy needed that requires inpatient care (ie, needed beyond observation care time frame (eg, 24 hours) - this was not present in this case. There was no need for prolonged care as the patient was 34 1/7 weeks at presentation.
9)	Inability to stop preterm labor - This was not present as the patient was noted to have no cervical change and no ongoing preterm labor.
In this case, none of the criteria for admission to acute inpatient level of care were supported based upon review of the medical records and the MCG Care Guideline.
These recommendations are in agreement with the recommendations of ACOG. In this case, the member was admitted preterm at 34 1/7 weeks with threatened preterm labor without documented cervical change (as this was stable on two exams) in the setting of contractions. There was no evidence of preterm labor as there was no cervical change documented. In this case, the standard of care would be observation for cervical change. Preterm labor was not present as there was no cervical change documented in the charting by the physician. If cervical change had been detected, steroids would be administered but magnesium and tocolysis would not be recommended beyond 33 6/7 weeks. This may be continued to achieve 48 hours of tocolysis to complete steroids when a patient is less than 34 weeks gestation which was not the case with this patient who was 34 1/7 weeks. In this case, there was no cervical change documented. In this case, the use of magnesium would not be supported as medically necessary. 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 actually translates into statistically significant neonatal benefit." Thus, this would not be supported and this was not medically necessary for tocolysis as used in this case. Given the review of the ACOG recommendations and the MCG Care Guideline, there was no medical necessity for admission to acute inpatient level of care.
In this case, the care provided could have been provided at a lower level of care. In this case, the patient had no signs or symptoms of preterm labor. She was on magnesium but this was not indicated and could have been discontinued as steroids were being completed at beyond 34 0/7 weeks gestation. None of the criteria for admission to acute inpatient level of care were supported based upon a review of the medical records and the MCG Care Guideline and ACOG recommendations.