Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Vaginal bleeding.

Treatment:  Inpatient services.

The insurer denied coverage for inpatient services.  The denial is upheld. 

This patient is a female gravida 5 para 0222 at 32.4 weeks gestational age, who presented to the Hospital.  The patient was transferred to labor and delivery from one hospital due to vaginal bleeding.  The patient stated that she experienced mild bleeding and passage of a small blood clot.  The patient denied feeling abdominal pain or contractions, and reported presence of fetal movement.  The patient also reported a history of low lying placenta which had resolved on the last sonogram.  The patient's obstetrical history was significant for 2 preterm vaginal deliveries due to preterm labor; with no other complications of pregnancy.  The patient's examination showed a small blood clot but no active bleeding.  The patient's cervix was 1 cm dilated.  The patient was admitted to labor and delivery due to vaginal bleeding and a history of preterm deliveries, with a plan that included continuous monitoring, Celestone for lung maturity, and magnesium for tocolysis.  The patient was tested positive for a substance, and the social worker was involved in her management.  After absence of bleeding for 24 hours, the patient was discharged home.

Based on the review of the medical record, the patient presented with an episode of bleeding with no evidence of placenta previa.  There were minimal contractions and fetal heart rate was reactive.  During this patient's inpatient stay, there was no evidence of bleeding, cervical dilation or fetal jeopardy.  Because the patient tested positive for a substance, social worker was involved in this patient's care.  Based on progress notes on two specified dates the patient was clinically stable.

According to the MCG guidelines, the following clinical condition may qualify the patient for inpatient admission:  1) Condition requiring premature delivery, 2) Fetal distress or demise, 3) Preterm prelabor rupture of membranes, 4) Significant maternal disease, 5) Vaginal bleeding, 6) Complications of tocolytic treatment, 7) Continued fetal monitoring that require inpatient care, 8) Tocolytic therapy needed that requires inpatient care, or 9) Inability to stop preterm labor.  In this case, this patient did not have any of the above conditions.  While the patient presented with complaint of vaginal bleeding, examination showed no active bleeding.

According to MCG guidelines, observation care is appropriate for patients with one or more of the following:  1) Condition requiring premature delivery suspected, 2) Preterm premature rupture of membranes suspected, 3) Suspected maternal infection, 4) Ongoing uterine contractions (tocolytic therapy needed, monitoring of cervical changes needed), 5) Fetal distress suspected, or 6) Suspected placenta previa, vasa previa or placenta accreta.

Based on the review of the medical record, this patient was stable despite the episode of vaginal bleeding and clot reported by the patient.  Thus, the patient could have been observed for any additional bleeding or cervical dilation as observation status.  Once the provider ascertained that both the patient and the fetus were stable, the patient could have been discharged home to be followed up as an outpatient.  Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for inpatient services for dates of service specified is upheld.  The medical necessity is not substantiated.