Appeal type: Medical necessity
Decision: Upheld

Diagnosis Short Cervix
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient presented to the emergency department at 22 weeks and 4 days gestation with a short cervix who had been discharged 2 weeks prior. The patient presented to the emergency room for preterm cervical dilation with prolapsing membranes with a rescue cerclage in place. She was admitted for the diagnosis of cervical insufficiency. A cerclage revision was performed in the operating room after presentation. The patient was continued on prophylactic antibiotics and azithromycin 500 milligrams (mg) daily and ampicillin 2 g every 6 hours with indomethacin 25 mg every 6 hours for 48 hours of topical lysis post procedure. The patient experienced urinary retention and a Foley catheter was placed after the procedure and removed  (the day following placement). The patient was discharged to home.
The patient's past medical history included asthma with no prior intubations. Her most recent asthma attack was 1 year prior. The patient's surgical history was noted for dilation and curettage on 2 occasions and a prior cerclage placement approximately 2 weeks prior to admission. The patient was noted to have positive fetal heart tones on evaluation. She was sent over from the office for a plan of cerclage revision on the following day. She was admitted to the hospital for intravenous (IV) ampicillin, azithromycin and oral Indocin. The patient was added to the operating room schedule and made nothing by mouth after midnight for planned of cerclage based upon this presentation. Her vital signs were stable of presentation was blood pressure of 106/57 with a heart rate of 105. Respiratory rate was 16 and normal and oxygenation was 100% on room air. The patient reported no complaints. She denied leakage of fluid, vaginal bleeding, or contractions. She denied fever, chills, chest pain, shortness of breath, dysuria or abnormal vaginal discharge. The patient was given a diagnosis of short cervix with a transvaginal cervical length of 0.2-0.3 centimeters (cm) with funneling on July 2 which resulted in a cerclage placement on July 3. The patient was on albuterol when necessary for her asthma. The patient remained stable. Patient was admitted with preterm cervical dilation with prolapsing membranes with a rescue cerclage in place. She was planned for cerclage revision. The patient had no signs of preterm labor and a plan was made for the prophylactic antibiotics and Indocin prior to surgery. The patient was without signs or symptoms of preterm labor, vaginal bleeding or vaginal discharge.
The patient's surgery was completed with no complications with an estimated blood loss of 120 cubic centimeters (cc). Her output was none and the patient was discharged to the post-anesthesia care unit (PACU) after surgery. The patient was noted to have some urinary retention after the procedure and had an indwelling Foley catheter placed and then removed.
Given the stable status, the patient had follow-up arranged in the outpatient setting. At issue is the medical necessity of an inpatient stay.

The acute inpatient level of care was not medically necessary in this case in this patient without any acute status for preterm labor or delivery. Admission to acute inpatient care would have been deemed medically necessary under the Milliman Care Guidelines (MCG) Guideline "Preterm Labor, Threatened" for the following:
1)  Condition requiring premature delivery (eg, preterm premature rupture of membranes with nonreassuring fetal status, chorioamnionitis) - this was not present
2)  Preterm rupture of membranes- this was not present
3)  Fetal distress or demise- this was not present
4)  Significant maternal disease - this was not present. She had asthma that was well controlled.
5)  Significant vaginal bleeding or vaginal bleeding with known placenta previa, vasa previa, or placenta accreta - this was not present
6) Complications of tocolytic therapy - this was not present and was not indicated.
7) Inpatient admission required for continued fetal monitoring that requires inpatient care, tocolytic therapy needed that requires inpatient care, Inability to stop preterm labor, and none of these are present. There was no need for ongoing tocolysis as the patient was quiescent without any progress toward labor or delivery. The indocin used was oral. The performance of the cerclage revision in this case would be performed as an outpatient. Based upon a review of the medical records and MCG Care Guideline, the patient would be provided care at a lower level. The MCG Care Guideline entitled "Obstetric and Gynecologic Surgery or Procedure GRG" states that cervical procedures are performed at an ambulatory or observational level of care. A lower level of care would be appropriate in this case. The care provided such as monitoring, Ampicillin, Azithromycin, indocin, and revision of cerclage would be provided at a lower level. The surgical procedure and surrounding care is an outpatient procedure as there are no inpatient indications for admission.