Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intrauterine growth restriction. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 
The denial is upheld. 

This is the case of a female who was referred to labor and delivery to receive a betamethasone injection because of a diagnosis of intrauterine growth restriction (IUGR). She was found to have elevated blood pressure. She was admitted to rule out preeclampsia. The fetal heart tracing was reassuring. Protein in urine was negative. Laboratory evaluation did not show any abnormality. Her blood pressure stabilized. A 24-hour collection was performed and was negative. The patient was discharged. 

According to the medical records, the patient was admitted for pregnancy induced hypertension evaluation and betamethasone administration. This pregnancy is said to be complicated by IUGR. For patients with IUGR, serial ultrasound evaluation of fetal growth, fetal behavior (biophysical profile or nonstress test), and impedance to blood flow in fetal vessels (Doppler velocimetry) represent the key elements of fetal assessment and guide pregnancy management decisions. The purpose is to identify those fetuses that are at highest risk of in utero demise and neonatal morbidity and thus may benefit from delivery. Admission for fetal monitoring is not medically necessary. The patient could be evaluated daily as an outpatient with nonstress tests and biophysical profile. 

Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 or higher, or diastolic blood pressure of 110 or higher) should be diagnosed with preeclampsia with severe features. These severe ranges of blood pressure increase the risk of morbidity and mortality. 

According to the American College of Obstetricians and Gynecologists (ACOG), ambulatory management at home is an option only for women with gestational hypertension or preeclampsia without severe features and requires frequent fetal and maternal evaluation. Hospitalization is appropriate for women with severe features. This patient did not have preeclampsia. She had a mild elevation in blood pressure that stabilized without any medication. In addition, there was no protein in the urine and her laboratory evaluation was normal. 

This patient could have received her betamethasone shot and observed. Once her laboratory evaluation returned normal and her blood pressure stabilized, she could have been sent home without the need for admission. 

Please note that neither the patient nor the fetus were in any jeopardy. Fetal heart rate was reassuring. There was no evidence of ruptured membranes. 

Milliman Care Guidelines (MCG) guidelines list the following clinical indication for admission: 
- Condition requiring premature delivery 
- Delivery 
- Fetal distress or demise  
- Preterm labor and positive Fetal fibronectin (fFN) 
- Significant maternal disease, infection or comorbidity as cause
- Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accrete 
- Continued fetal monitoring
- Tocolytic therapy that requires inpatient care 
- Complications of tocolytic treatment.

This patient did not have any of the above. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.