Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm Labor.
Treatment: Inpatient hospital.

The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

This patient is under consideration for admission to acute inpatient level of care. This patient is a Gravida 1 Para 0 who presented with a referral due to a short cervix. She was admitted for possible cervical incompetence. The patient was evaluated in the consideration of etiology being cervical insufficiency versus preterm labor was considered. The patient was counseled for possible cerclage or vaginal progesterone for cervical etiology of a short cervix. The patient expressed understanding. Contractions were visualized on tocodynamometer (toco) and ultrasound. The patient underwent a complete blood count (CBC), urinalysis and type and screen to evaluate for infection and she was started on Indomethacin 50 mg (milligrams) once followed by 25 mg every 6 hours. Ancef was given for a possible urinary tract infection and preoperative optimization. She was admitted for monitoring and reevaluation and if there was no evidence of preterm labor there was a plan for possible cerclage placement.
The patient underwent placement of 2 circumferential sutures of Prolene for a McDonald cerclage placement.

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

The inpatient admission was not medically necessary at the acute inpatient level of care status for this patient given the diagnosis of short cervix without evidence of preterm labor with a plan of possible cerclage placement. The care provided could have been provided at a lower level of care such as outpatient/observation. This patient was noted to have a short cervix and was asymptomatic. There were contractions present that were not detected by the patient with a closed cervix and this was a previable gestation. The patient underwent an uncomplicated McDonald cerclage placement for a short cervix and presumed incompetent cervix on the day following admission and after treatment with oral Indocin tocolysis. There is no strong data to support cerclage for prevention of preterm birth among the patients without a prior preterm birth (as this was her first pregnancy) and a short cervix as was the case as presented.

Based on review of the medical documentation and the Milliman Care Guidelines (MCG) Health Guidelines [1], there was no medical necessity for acute inpatient admission as the patient had no prolonged need for tocolytic therapy, no rupture of membranes, no suspected amnionitis, no vaginal bleeding, no maternal infection, no significant maternal disease comorbidity. There was no delivery or fetal demise. There was also no condition that indicated a preterm delivery. There was also no previa. The patient in this case did not have cervical change documented during the stay and there were no contractions. Thus, there were no criteria for admission to acute inpatient status. The MCG Health Guidelines do allow for alternatives to inpatient admission, which include home care or outpatient admission for observation level of care. The provided care did not require the inpatient level of care by these guidelines. The inpatient admission in this case is not supported by the care provided and indications as found in the medical records and the MCG Health/American College of Obstetricians and Gynecologists and, thus the inpatient level of care is not medically necessary in this case.