Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

The female patient was born at 37.6 weeks estimated gestational age. The neonate was delivered by a scheduled Cesarean section. Artificial rupture of membranes occurred one minute prior to delivery. The Apgar scores were 8 and 9 at one and five minutes, respectively. 

The infant developed respiratory distress at 13-15 minutes of age, including moderate substernal retractions and an oxygen saturation in the 70's. She initially received supplemental oxygen (40%) by blow-by administration. Because of retractions and the need for oxygen, the neonate was then placed on continuous positive airway pressure (CPAP) +5 and 50% oxygen. She was then taken to the nursery for further stabilization and management, where she transitioned to unassisted room air within three hours. The infant was observed, and then care transitioned to rooming in with the mother and normal newborn care orders. 

The infant's weight was decreased 8.17% from her birth weight and then decreased 11.6% from birth weight. The infant was hemodynamically stable, breathing unassisted room air and in an open crib. The neonate had been exclusively breast feeding, but due to the excessive weight loss, supplemental feeding methods were discussed and put in place. The infant gained weight over the night and was discharged to home. Her weight was still decreased 10.74% from birth weight, but the mother's milk was in and alternative feeding strategies were in place. 

At issue is the medical necessity of the Neonatal Intensive-Care Unit (NICU) inpatient level of care. 

The health plan's determination of medical necessity is upheld in whole. 

No, the requested health service/treatment of Inpatient stay was not medically necessary for this patient. 

The neonate in this scenario required assistance with transitioning from in utero to extrauterine life. [1,3] She exhibited mild respiratory distress which resolved in a few hours. Neonates born by Cesarean (C)-section frequently have difficulty clearing the retained lung fluid and manifest as respiratory distress with increased work of breathing and some desaturations that may require supplemental oxygen. [1,3] The neonate was monitored for a few hours and then couplet care with newborn nursery orders were put in place. 

The infant exhibited excessive weight loss during the first few days of life. [4] The infant was exclusively breast fed and the mother's milk supply had not been established. Alternative feeding strategies were implemented, and the infant began to demonstrate weight gain prior to discharge. [5] The neonate was discharged with follow-up care arranged. Neonates born by C-section remain with their mothers until discharge of the mother. [6,8] 

Although the neonate required care in the hospital setting, the monitoring of respiratory status, glucose concentrations, feeding, and weight are part of the normal newborn infant care. [4,5] The neonate did not require intravenous fluids, did not require intravenous antibiotics, and received supplemental respiratory support including oxygen for a few hours after birth. The infant's needs are consistent with transitional care needs for a neonate born by C-section. 

Therefore, the requested health service/treatment of NICU Inpatient stay was not medically necessary for this patient.