Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Bronchopulmonary Dysplasia, Pulmonary Hypertension and a Neurodevelopmental delay. 
Treatment: Continued inpatient stay. 

The insurer denied coverage for continued inpatient stay. 

The denial is upheld. 

This case involves an infant with a history of extreme prematurity as well as severe bronchopulmonary dysplasia, pulmonary hypertension and a neurodevelopmental delay.  She presented to the hospital as a transfer after being hospitalized with lethargy and emesis.  She was on assist-control volume ventilation and later a ventilator weaning protocol was started.  Interdisciplinary note indicated she continued via trach collar with intermittent wheezing.  The documentation indicated she did tolerate a Heat Moisture Exchange (HME) valve.  She does have a gastrostomy tube and it was noted she did have the ability to roll from prone to supine with minimal assistance.  She has been participating in therapy where it was recommended she continue services.  She has demonstrated improved upper extremity strength.  The documentation indicated a home assessment was performed where it was noted that it was passed.  She was in need of private duty nursing once discharged.  A note indicated there were no acute respiratory issues with no recent exacerbation.  She was weaned off the ventilator completely and tolerating her trach collar 28% (percent).  She started Passy-Muir trials and was on sildenafil for pulmonary hypertension.  It was recommended she continue with medications.  An additional summary report indicated she was stable on a trach collar intermittently with congestion.  She did require a trach change due to thick secretions.  The documentation does indicate private duty nursing hours up to 20/day were authorized pending discharge.  She was seen where she remained active and alert with no retractions and clear lungs on examination.  The documentation indicated this was the first day she had no wheezing.  It was recommended they perform laboratory studies prior to discharge.  She has had poor weight gain over the prior 2 weeks and a trial of 26-calorie plus water flushes was recommended. According to the physician, appropriate weight gain and stable respiratory pattern must be present prior to discharge.  The documentation indicated she continued with treatment and continued to improve.  She was discharged with instruction to follow-up.

The inpatient stay is not medically indicated, as the patient did not have acute inpatient needs at that point. 

Respiratory: The facility states that they "have the ability to manage children who continue to require highly complex care ...who are dependent on a ventilatory with high pressure." While there is no doubt that this is true, from the dates in question, the patient did not require a ventilator with high pressure. She completed weaning. She did require albuterol every 6, then every 8 hours and diuretics, but these are medications typically given at home.  Medications: Part of the justification is that the patient required 15 doses of medications per day. These were medications delivered by g-tube or nebulizer. Home nursing was approved for 20 hours per day, in part to administer these medications. 

Physical therapy (PT)/ Occupational therapy (OT)/ Speech therapy (ST): These are services that can be provided as an outpatient or in the home.  Additionally, parents have been taught to provide some physical therapy at home with good outcomes. 

Weight gain: The patient presented at 5.445 kilograms (kg), which was 0.2% for weight. The facility did an excellent job with her growth. A note indicates an average 17 gram/day weight gain at that point. The weight is documented (25-30%) and (32%) at a later time. The patient was taking bolus gastrostomy tube feeds every 4 hours which are reasonable for home, especially with near-constant home nursing. Minor formula modifications can be done at home, and certainly weekly weights could be obtained if need by via outpatient visits to the pediatrician or by the home nurse. 

There did not appear to be other issues cited in the justification for stay. The health plan acted reasonably with sound medical judgment. 

Based on the above, the medical necessity for the continued inpatient stay is not substantiated. The insurer's denial is upheld.