Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
The patient was pregnant and presented to the hospital with complaints of abdominal pain. A renal ultrasound revealed mild to moderate right hydronephrosis. She was diagnosed with a urinary tract infection. She was evaluated by urology who recommended antibiotics for the urinary tract infection and outpatient follow up. The patient was given intravenous (IV) fluids and symptoms improved. She was also given Ceftriaxone and indomethacin. The patient's condition improved after treatment, and she was discharged. 

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. During this admission, there was no documentation of any cervical changes. Repeat cervical examination did not show any changes. So, the patient was not in preterm labor. The patient was complaining of abdominal pain. She was diagnosed with mild to moderate right hydronephrosis. She was evaluated by urology who recommended treating the patient's urinary infection and outpatient follow up.

Ideally, this patient would have been observed in labor and delivery, received IV fluid and then reevaluated a few hours later. If upon reevaluation, no cervical changes occurred then she would be sent home on oral antibiotics to treat her urine infection as recommended by urology.

Please note that neither the patient nor the fetuses were in any jeopardy. There was no bleeding, and vital signs were stable. Fetal heart rate was reassuring. There was no evidence of ruptured membranes. 

The management that this patient received during her admission could have been easily done in a less acute setting: Once the provider ascertained that there was no evidence of preterm labor, (no change in cervical status after a few hours of observation) the patient could have been sent home after being hydrated. 

Note that physiologic hydronephrosis occurs in up to 80% of women. According to Milliman Care Guidelines (MCG) admission is indicated for one or more of the following:

Condition requiring premature delivery
Fetal distress or demise
Preterm prelabor rupture of membranes
Significant maternal disease
Vaginal bleeding
Complications of tocolytic treatment
Continued fetal monitoring that require inpatient care
Tocolytic therapy needed that requires inpatient care
Inability to stop preterm labor.

Observation care is appropriate for patients with one or more of the following:

Condition requiring premature delivery suspected 
Preterm premature rupture of membranes suspected
Suspected maternal infection
Ongoing uterine contractions (tocolytic therapy needed, monitoring of cervical changes needed)
Fetal distress suspected
Suspected placenta previa, vasa previa or placenta accreta

Based on the above, admission to the hospital was not medically necessary. This is in accordance with the standard of care and Milliman guidelines.

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

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