Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenital heart disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The insurer has denied coverage for a hospital admission. In their Final Adverse Determination letter, they write that based on the information provided, the patient did not have any conditions to meet the criteria such as a disease or condition like an active infection, bleeding disorder, dangerous heart rhythm or unstable blood pressure, complex surgery that required a longer recovery after surgery than usually expected, or a severe complication from the procedure. 

The hospital is appealing. In an appeal letter the hospital writes that the services provided to this infant were medically necessary, reasonable and provided at the appropriate level of care. This child had extensive hereditary cardiac disease and required a cardiac catheterization to evaluate effectiveness of treatment. The patient required continuous cardiopulmonary monitoring, supplemental oxygen, IV (intravenous) medications, input and output monitoring, bronchodilators, and lab monitoring. 

This is a child with very complex congenital heart disease who was admitted for a follow-up cardiac catheterization which is being denied by the insurance carrier and appealed by the admitting hospital.

The child was born with heterotaxy syndrome with a right dominant atrioventricular canal and an associated hypoplastic left ventricle as well as a hypoplastic aortic arch with coarctation of the aorta and total anomalous pulmonary venous return. At 13 days old the patient had an aortic arch repair and a pulmonary artery band. At 3 months old, the patient underwent a cardiac catheterization which revealed an adequate pulmonary artery band, but an element of reactive pulmonary hypertension was determined, and the patient was therefore placed on Sildenafil. The patient was followed closely, and the decision was made to perform a follow-up cardiac catheterization to assess the need for continuation of Sildenafil and evaluate the next surgical step in a single ventricle palliative repair.

A careful review of the enclosed medical record was made and the recommendation for reversal of the denial is being made. The rationale for this decision follows.

In my opinion, the Ambulatory Surgery Exception Criteria (Milliman Care Guidelines (MCG) Health General Recovery Care) has been met in this case. Due to this child's complex cardiac disease, the patient does have chronic hypoxemia. The patient's oxygen saturation on the pre-catheterization exam was 88%. During recovery the patient had oxygen saturations reported in the 50s and 60s. In addition, due to the patient's recent respiratory issues and history of a labile pulmonary vascular bed being treated with Sildenafil, the patient required careful frequent airway and pulmonary monitoring in an inpatient setting. Although there were no complications, this procedure based on the complexity of the anatomy and the need for extensive data to prepare this child for a staged "single ventricle" should be labeled as unusually difficult. All of the rationale above meets the Ambulatory Surgery Exception Criteria and makes the in-hospital Congenital Cardiovascular Care Unit (CCVCU) admission appropriate.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a hospital admission is substantiated.