Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hyperbilirubinemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

This is a premature infant born via cesarean section. Apgar's were 9 and 9 at one and five minutes, respectively. Initially, there was respiratory distress (retractions and grunting) treated with nasal Continuous Positive Airway Pressure (CPAP).  On Day 2, enteral feeding was initiated via orogastric (OG) tube. On Day 3 oral feedings were initiated. The infant was off CPAP and on room air with normal oxygen (O2) saturations. On Day 4, hyperbilirubinemia (total bilirubin 12.6) was treated with phototherapy. On Day 5, phototherapy was discontinued for a total bilirubin of 7.4 at 07:55.  Intravenous (IV) fluid was off and feedings were being advanced by 5 milliliters (ml) every other feeding until 40 ml every 3 hours. On Day 6, the total bilirubin (post-phototherapy) was 8.1. The infant weighed 2430 grams (increase of 10 grams) and was feeding 40 ml every three hours.   

Both hearing and Car Seat tests were passed.  The progress notes errantly stated that the total bilirubin was 9.1 the prior day. There was blood bilirubin test performed.   There was no documentation as to why the infant remained hospitalized. The following day, the total bilirubin level was 11.8 and phototherapy was started. Oral (po) intake was 30-40 ml of expressed breast milk every 3 hours. The next day, the total bilirubin was 6.5. Phototherapy was discontinued and the infant was discharged.

While a weight loss from the prior day was documented and could be a reason to withhold discharge, the providing Neonatologist did not clearly document the reason(s) for a continued stay other than "The infant requires inpatient management in the neonatal intensive care unit on continuous monitoring due to risk of cardiopulmonary deterioration."  This was not supported by the infant's course which had been without any cardiorespiratory problem for 4 days. Of note, despite post-phototherapy rebound, no bilirubin measurement was done. Thus, one must assume hyperbilirubinemia was not a contributing concern for the continued stay. For these reasons, the continued stay on one particular day is denied. 

However, of note, a bilirubin level of 11.8 was obtained the following day when the infant was approximately 158 hours old. The treating Neonatologist chose to cancel a planned discharge and resume phototherapy.  Although the American Academy of Pediatrics has provided a guideline for management of infants born at 35 weeks gestation or later (2004 and updated in 2022), there is no such widely accepted guideline for determining the threshold for phototherapy in infants 34 weeks gestation or less.  Many experts believe preterm infants are at greater risk for bilirubin induced neurologic dysfunction (BIND) than their term counterparts and, therefore, opt for treatment at lower levels than in term infants at similar post-natal ages.  One such approach has been published in UpToDate. Therein, the authors recommend for "Gestational Age 34 to <35 weeks - Total Bilirubin of 12 to 14." In this context, the providing Neonatologist was acting within the accepted standard of care in resuming phototherapy and the following day, with a significant decrease in the bilirubin level, discontinuing treatment and discharging the infant to home. 

In view of the above, the denial for a continued stay on one day is upheld.  However, the denial for a continued stay on the following two days is reversed.

Based on the above, the insurer's denial must be modified. 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 full hospital admission with the exception of one day is substantiated.