Appeal type: Medical necessity
Decision: Upheld

Diagnosis Short Cervix
Inpatient Stay
The insurer denied the inpatient stay.
The determination is upheld.

This patient is a gravida (G) 4 para (P)3 living (L)3 who was admitted to the hospital at 30-0/7 weeks gestation with a chief complaint of falling on her stomach after tripping on sidewall. The patient reported tripping on the sidewalk on the day of admission and braced her fall with her hands across her abdomen. The patient denied any abdominal pain, hitting her head, loss of consciousness or dizziness. The patient denied contractions, vaginal bleeding or decreased fetal movement. She had no leakage of fluid. Her prior obstetrical history was noted for her first pregnancy delivery at 41 weeks gestation and her second pregnancy delivery at 41 weeks by induction of labor. Her third pregnancy was delivered by induction of labor at 41 weeks by vaginal birth after a Cesarean delivery. The patient's medical history was negative. The patient denied taking any medications. She reported no known allergies. The patient was noted to have no other risk factors in pregnancy which included chronic hypertension, gestational hypertension, preeclampsia, gestational diabetes, gestational diabetes, postpartum hemorrhage, shoulder dystocia, preterm delivery for prior history of venous thromboembolic disease. She was a nonsmoker who does not use alcohol or recreational drugs.
On examination, the fetal heart rate was in the 140s with a moderate variability and present accelerations for category 1 and reassuring nonstress test. The patient was noted to have no contractions present. A pelvic exam noted her to be 0 centimeters (cm) dilated, 90% effaced, -1 station and intact membranes were assured. An ultrasound was performed which noted the presentation to be oblique with a funic presentation. The placental location was posterior fundal and the fetus weighed 1264 grams (g). A biophysical profile score was also completed which was reassuring at 8 of 8. The patient was admitted for cervical insufficiency and found to have a short cervix during biophysical profile. The patient was admitted for betamethasone, magnesium and observation.
Following admission, the patient was resting comfortably without complaints. She denied shortness of breath, chest pain, dizziness or nausea or vomiting. She also denied vaginal bleeding. She reported good fetal movement and voiding without difficulty. The patient was on magnesium sulfate for neuro protection and betamethasone. Estimated fetal weight was reassuring.
Laboratory studies revealed the patient be O positive (+) with a negative antibody screen. She had a normal white blood cell count 5.2. Her hemoglobin was 10.2 with a hematocrit of 30.9% and platelets of 168. Coagulation studies were noted to be normal. The patient had a negative clean catch urine specimen. There was no evidence of infection. The patient had a normal basic metabolic panel with a creatinine of 0.4. The patient was negative for gonorrhea and chlamydia. The patient was also noted to have a normal umbilical artery Doppler at 2.4.
The patient received 2 doses of betamethasone and completed magnesium for neuro protection. Following this therapy, the patient remained asymptomatic and was discharged to home with follow-up in the outpatient setting arranged. Fetal status remained reassuring throughout hospitalization. At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary for this patient for the presentation of cervical incompetence. This patient was admitted to the hospital with an asymptomic short cervix. She was in her fourth pregnancy (after 41 week deliveries with her prior three pregnancies). The patient had experienced a fall and was noted incidentally to have a short cervix in the absence of contractions, fetal distress, or abnormal lab values. There were no complications of the pregnancy and this was an incidental finding by ultrasound in the outpatient setting. She had no complaints of contractions. Given a short cervix, she was admitted to the hospital for magnesium for neuroprotection and a course of celestone. This was an initial appropriate intervention given the potential risk for preterm birth in completing celestone. However, other interventions were not needed at that time given the lack of dilation of the cervix. Intravenous (IV) magnesium was given for neuroprotection for a short course. This was reasonable based upon recommendations of American College of Obstetricians and Gynecologists (ACOG) at this gestational age. 
The patient had no complications of a less than 24 hour course of magnesium for neuroprotection and did not have a documented cervical change to support preterm labor as recommended by the American College of Obstetricians and Gynecologists (ACOG) and the Milliman Care Guidelines (MCG) Care Guideline Preterm Labor, Threatened. The patient had no condition that required preterm delivery. There was no preterm rupture of membranes, chorioamnionitis, or nonreassuring fetal status. The patient had intact membranes throughout her hospitalization and there was no preterm rupture of membranes noted. There was no fetal distress or demise present. There was no significant maternal disease that required inpatient treatment. There was no vaginal bleeding present in this case. There was also no abnormal placentation reported by ultrasound. There were no complications of tocolytic therapy (magnesium for neuroprotection) reported and there was no ongoing cervical change based upon the closed cervix and lack of contractions. There was also no need for inpatient admission in this case as continued fetal monitoring was not necessary, tocolytic therapy was not supported by the guidelines of MCG or ACOG, and there was no present preterm labor documented for the need for a Cesarean or vaginal delivery. Based upon the review of the medical record, none of these guidelines were met for admission to acute inpatient care.
The care provided could have been provided at a lower level. Given the lack of need for intervention beyond the administration of steroids and initial magnesium for neuroprotection, there was no need for acute inpatient hospital level of care in this case.