Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth/Other/Pelvic and Groin Pain
Treatment: Inpatient Hospital Services
The health plan denied the requested inpatient hospital services as not medically necessary. The health plan's determination is upheld.

The patient in this case is under consideration of medical necessity for admission to acute inpatient level of care. In this case, the patient is a female at 25-2/7 weeks gestational age with presentation for complaints of pelvic pain and groin pain when she stands up. The patient reports the pain to be sharp at 6/10 and she denied contractions, leaking of fluid, vaginal bleeding, and reported good fetal movement. She reported a history of short cervix in the last pregnancy and was on Prometrium. The patient had a prior history of chlamydia. The patient had a prior cesarean delivery for breech. She denied allergies. The antepartum course was reported as uncomplicated. She had a prior termination of pregnancy x 1 reported. At presentation, the patient was afebrile at 37.C. She had a normal blood pressure of 108/59 millimeters of mercury (mmHg). She had a normal heart rate of 67 beats per minute (bpm) with normal respiratory rate of 16/minute. The cervix was examined and was noted to be closed. The fetal status was reassuring and Category I. There were no fetal concerns on monitoring. An ultrasound was performed and noted the placenta to be posterior, breech, and maximal vertical pocket of 3.83 centimeter (cm) which was normal. The patient was admitted for evaluation and routine orders were entered. She was to have prenatal labs with urine toxicology screening and urine culture. Group B Streptococcus (GBS) was also sent. COVID polymerase chain reaction (PCR) was also sent. Betamethasone was also ordered.

I uphold, in whole, the health plan's determination of medical necessity in this case.

In this case, the care as rendered for the patient with a short cervix without signs or symptoms of threatened preterm labor, would not have required admission to the acute inpatient level of care. The care as provided and was appropriate for this patient's management of threatened preterm labor would be appropriate at an alternate level of care, given the lack of need for delivery or moving to delivery. In this case, the patient was noted to have a closed cervix on exam without symptoms but with a short cervix at 1.1 cm and would be indicated for antenatal corticosteroids. These were given and there were no contractions and thus, Magnesium was not given. She was also given cultures and GBS assessment. She completed a course of corticosteroids.

 In this case, there was no need for admission to inpatient care for this care to be provided in the form of steroids and monitoring. In this case, there was no delivery or indication for delivery which would have moved the care to be medically necessary at the acute inpatient level of care by ACOG and peer reviewed literature. The care provided was as recommended by national standards of ACOG and could have been completed at an alternate level of care. This stay would not have been medically necessary at the acute inpatient level of care.