Appeal type: Medical necessity
Decision: Overturned

The patient is a gravida 3 para 2, at 35 weeks estimated gestational age who was admitted to the hospital for severe intrahepatic cholestasis of pregnancy. The patient's lab results were remarkable for a bile acid level of 235 micromole (umol/L) (normal is less than 12 umol/L). The patient also had transaminitis with an alanine aminotransferase (ALT) value as high as 108. The patient was admitted to the hospital until delivery  at 36 weeks estimated gestational age. The patient was discharged on postoperative day 3 when the transaminitis began to resolve. 

The health plan's determination is overturned in whole. 

Cholestasis with bile acids over 99 umol/L carries a stillbirth risk of up to 6.8% - more than twice the rate of preeclampsia. Cholestasis is well-known to result in stillbirths that have been documented just after reactive non-stress tests in the office. Therefore, in this unusual case, the inpatient management with testing performed several times per day was the only safe option.
This particular case of cholestasis is a highly unusual, but a seriously dangerous clinical situation. Intrahepatic cholestasis of pregnancy occurs in about 1-2% of pregnancies and is associated with sudden stillbirth. The mechanism is believed to be the deposition of bile salts in the placenta, causing vascular dysfunction. Multiple studies have shown that the risk of stillbirth correlates with the serum level of bile acids. Anything above 12 umol/L is considered abnormal, above 40 considered severe with risk for stillbirth, and above 100 considered very high risk for stillbirth. One recent study found a 6.8% risk of stillbirth for those with bile acids over 99, while concurrent metanalysis found a somewhat lower risk of 3.4%. Both those numbers represent a high risk for such a catastrophic outcome (death of a baby). This patient's bile acids were 235 umol/L, which is extraordinarily high. For comparison, the most recent study to look at the level of bile acids in relation to stillbirth found a high in their population of just 159 umol/L (the baby in that case died). This patient's physicians had an extreme level of concern for stillbirth given this unusual lab finding in a preterm patient. The condition is cured only by delivery, but delivery is not recommended in these cases until 36 weeks. The patient was admitted at 35 weeks to facilitate steroid administration (which is proven to improve neonatal outcomes in preterm deliveries) and then conducted the Cesarean delivery at 36 weeks.
There are no studies identifying the ideal fetal surveillance plan for cholestasis, so most physicians conservatively prescribe standard measures like non-stress tests and biophysical profiles. The absence of clear guidance on management of this condition is a result of the overall rarity of stillbirth. This case, with such a high level of bile acids, defies any conventional treatment of the condition and warrants extreme vigilance. The patient's physicians admitted the patient where monitoring could be performed several times per day and positioned her for quick action if fetal compromise was detected. They moved forward with a late preterm delivery as directed by the guidelines after steroid administration. The care could not have been safely conducted as an outpatient. An inpatient stay was medically necessary.