Diagnosis: Preterm labor

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

This is a pregnant adult patient with a history of a short cervix and cerclage placement. On a recent perinatal scan there was no measurable cervix. The patient was admitted for fetal monitoring, betamethasone and magnesium sulfate. The patient was not in preterm labor. The patient was discharged two days after admission.

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. During this admission, there was no documentation of any cervical changes. Repeat cervical examination did not show any changes. The patient was not in preterm labor.

Ideally, this patient would have been observed in labor and delivery, received intravenous (IV) fluids and then reevaluated a few hours later. If upon reevaluation, no cervical changes occurred then the patient would be sent home. If cervical changes did occur, then the patient would be admitted for tocolysis and further management. Please note that neither the patient nor the fetus were in any jeopardy. There was no bleeding, and vital signs were stable. Fetal heart rate was reassuring. There was no evidence of ruptured membranes.

The management that this patient received during the admission could have been done in a less acute setting. Once the provider ascertained that there was no evidence of preterm labor, (no change in cervical status after a few hours of observation) the patient could have been sent home after being hydrated.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the full hospital admission is not substantiated.