Diagnosis: Pregnancy
Treatment: Inpatient stay

The insurer denied the inpatient stay. The health plan's determination is upheld.

In this case, the patient is a female who presented at 27 1/7 weeks gestation with a chief complaint of preterm labor. The patient reported positive fetal movements and cramping. She denied vaginal bleeding, leakage of fluid, headache, chest pain, shortness of breath or chest pain. She had a reactive NST and vaginal exam noted her to be 3-4 centimeter (cm) dilated. She was sent over and repeat exam was 4/90%/-3 and intact. Fetal fibronectin was not collected. She was noted to have a blood pressure of 143/81.

The inpatient admission was not medically necessary for this patient with a dilated cervix without cervical change documented, regular contractions or bleeding. There was noted to be reassuring fetal assessment with uterine irritability on monitoring. There were normal lab values noted on CBC and CMP. There was no need for tocolytic therapy given the absence of cervical change or preterm labor as noted by contractions being absent. Magnesium in this case was used for a short course for neuroprotection and achieving steroids for transfer which was reasonable. There was no positive fetal fibronectin in this case. The patient had no change in the cervix based on exam during her hospitalization. There was no evidence of rupture of membranes or labor.
The Milliman Care Guidelines (MCG) for "Preterm Labor, Threatened" were not met.

There was maternal monitoring for the fetus and contractions, performance of an ultrasound for presentation, and administration of steroids and neuroprotective magnesium for 12 hours, but this is noted to be a treatment that is defined as a care plan that does not require admission under the MCG. This care can be provided at a lower level of care.