202006-129536
2020
United Healthcare Plan of New York
HMO
Pregnancy/ Childbirth
Inpatient Hospital
Medical necessity
Upheld
Case Summary
Diagnosis: ruptured membranes.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld.
This patient is under consideration for acute inpatient level of care for the indication of a 21-week pregnancy with vaginal bleeding, cramping and leakage of fluid (ruptured membranes). In this case, the patient presented with bleeding and premature preterm rupture of membranes (PPROM) at 21 2/7 weeks. The patient was noted to have a blood type of A positive. The patient had a white blood cell count 10.3. Glucose was normal at 92. Antibody screen was negative. The patient had a hemoglobin of 11.8 and normal complete metabolic count. At presentation, the patient was afebrile at 97.8°F with a heart rate of 108 and oxygen saturation 100% on room air. Blood pressure was 116/65. The patient denied pain or discomfort. The patient reported that she had soaked 2 pads at morning and had occasional leakage of fluid since that time. She also had cramping that started 30 minutes prior that was associated with shivering. She denied chills, fever, shortness of breath, chest pain, nausea, vomiting or changes in bowel movements or urinary complaints. Her review of systems was negative except for vaginal bleeding and pelvic pain.
Based upon a review of the medical records and the recommendations of the American College of Obstetrics and Gynecology (ACOG), the acute inpatient level of care was not medically for the indication of a 21 week pregnancy with vaginal bleeding, cramping and leakage of fluid (ruptured membranes). In this case, the pregnancy was previable (less than 23 weeks gestation) and would not have been considered in the management of the case. The patient had no signs of active blood loss or hemorrhage and had no evidence of infection or chorioamnionitis. Given the previable pregnancy, there was no role for fetal monitoring or planning for delivery or resuscitation of a viable infant. Rather there was monitoring for maternal signs and symptoms of excessive bleeding which was absent and maternal infection which was also absent. Given these findings, the care provided could be a lower level of care and would not have required acute inpatient level of care.