Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Apnea 

Treatment: Inpatient hospital services

The insurer has denied inpatient hospital services .The denial was reversed.

The patient is a child who was born before 40 weeks gestation and required 
Neonatal Intensive Care Unit (NICU) related to having a nuchal cord wrapped around her neck in utero. In the NICU, she required treatment with continuous positive airway pressure (CPAP), and there was difficulty weaning the CPAP on several occasions. The mother had noticed that the infant continued to have gasping episodes for two weeks since she was discharged which was unrelated to feedings. When there were two episodes of the infant gasping, breathing cessation and the patient turning blue, the mother brought her to the Emergency Room (ER) for evaluation.

In the ER, the child was noted to have a heart rate of 180 and a respiratory rate of 70. A chest x-ray, head ultrasound, EKG and blood testing were normal.  In view of the history of requiring CPAP in the NICU and the two cyanotic episodes with gasping at home, the ER physician decided to admit the child to the cardiac telemetry unit with a diagnosis of Brief Resolved Unexplained Event (BRUE). 

The insurer has denied the admission as being not medically indicated.

In the past, these events were termed "apparent life-threatening events" (ALTE). This term was broad and included a wide range of events and prognoses. Other previously used terms were "near-miss sudden infant death syndrome (SIDS)" or "aborted crib deaths," which were discarded because they incorrectly implied a direct association between these symptoms and SIDS. Because of the diverse presentations, causes, and prognoses of infants presenting with acute events, evaluation and management should be individualized.

For infants who do not meet criteria for low-risk BRUE, a brief period of in-hospital observation and monitoring (e.g., for 24 hours) immediately after the event may provide important clinical information. This is because additional episodes may be witnessed by medical personnel during the observation period, providing additional detail about the nature of the event. In addition, serious underlying medical conditions (e.g., hypoventilation or hypoxemia) may become apparent." 

The patient had a prolonged need for CPAP in the NICU with difficulty noted when trying to wean the assisted ventilation. When she developed two cyanotic episodes in the home, she was at risk for apnea.  Despite the fact that the testing in the ER did not detect an underlying cause for the apnea, it was appropriate to admit the child to the hospital for cardiac and respiratory monitoring. The child's age and recurrent episodes of gasping was concerning and the decision to admit the child for cardiac and respiratory monitoring was appropriate and consistent with the standard of care for a child with two unexplained episodes of cyanosis.

The health plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The acute inpatient admission was medically necessary.

Based on the above, the medical necessity for the inpatient hospital services is substantiated.  The insurer's denial is reversed.