Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suprapubic pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is an adult female, gravida one (G1), who presented to the hospital at 22.1 weeks with suprapubic pain. Her pregnancy was complicated by dichorionic diamniotic twins. The cervix was closed, 50% (percent) effaced, and the presenting part of the lowest twin was -3 station. Ultrasound revealed the presenting twin to be cephalic, 68% estimated fetal weight (EFW), and twin B to be transverse lie, 34.5% estimated fetal weight (EFW), and cervical length 1.6-2.1 centimeters (cm). The pregnancy was dated by embryo transfer as it was an in vitro fertilization (IVF) conception. Upon further questioning, the patient stated that her abdominal pain was more like mild irregular cramping approximately every three minutes. She had recently been started on 200 milligrams (mg) vaginal progesterone nightly. The patient's physical exam and vital signs were otherwise not remarkable. Although the cervix had not been documented to change, based on the short cervical length and the abdominal pain, the diagnosis of preterm labor was made. The patient was admitted to the hospital and indomethacin tocolysis was initiated. The uterine contractions subsided, and the patient was discharged home undelivered. 

The health plan contends that the admission was not medically necessary because the patient did not have severe problems such as labor pains that did not improve with early treatment, low blood pressure or high heart rate that does not improve with early treatment, fever, serious infection, or heavy bleeding, and cites ORG M-287 Preterm Labor, Threatened. The facility contends that the admission was medically necessary based on presenting factors, risk factors, and treatment received and cites Milliman Care Guidelines (MCG) M-287 Preterm Labor, Threatened ORG.

The proposed treatment was medically necessary.

When the diagnosis of preterm labor is made and tocolysis is administered, patients are generally admitted to the hospital for monitoring of treatment response as well as for complications of preterm labor such as ruptured membranes, chorioamnionitis, tocolytic complications, and progress of labor. Labor has classically been diagnosed by changes in the physical examination of the cervix and tocolysis is limited to pregnancies that have reached the point of ex-utero viability and prior to 34 weeks, at which time the risk of prematurity no longer exceeds the potential benefits of continuing pregnancy. These parameters have undergone evolution in recent years to incorporate a cascade of diagnostic tests to make the diagnosis as well as an extension of neonatal viability to 22 weeks. By virtue of the short cervix, this patient satisfies criteria for the diagnosis of preterm labor based on the diagnostic test cascade despite the lack of demonstrated cervical change. In this case, all estimates of gestational age exceed 22 weeks; therefore, the pregnancy would be considered viable in terms of prematurity by the new criteria. The patient was a candidate for the tocolytic therapy received and therefore the admission was medically necessary.