Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Apnea
Treatment full hospital admission
The insurer denied coverage for full hospital admission
The denial is upheld

This is the case of an infant female, and this was the third admission since birth. Prior admissions included: 1) initial Neonatal Intensive Care Unit (NICU) hospitalization after birth for suspected sepsis and meconium and 2) Pediatric Intensive Care Unit (PICU) admission for management of breath holding/questionable brief resolved unexplained event (BRUE). The patient was admitted to the PICU upon the recommendation her primary doctor (with prior PICU and Pulmonologist approval) for "observation and close monitoring of saturation of oxygen (O2) and any episode of apnea". According to the History of Present Illness (HPI), "as per mother this episode has improved". There was occasional spit up after feeding. On examination, the infant was fully saturated (100%) in room air. Other than suprasternal notch retraction, there were no adventitious findings on physical examination. No hypoxia or apnea was observed during the PICU stay. 
   
According to MCG: Admission is indicated for 1 or more of the following: 

1)	Unexplained episode of cessation of airflow (breathing) lasting 20 consecutive seconds or longer
2)	Unexplained episode of cessation of airflow (breathing) lasting less than 20 consecutive seconds with 1 or more of the following:
o	Heart rate less than 100 beats per minute
o	Oxygen desaturation to less than 80%
o	Cyanosis
o	Pallor
o	Hypotonia

None of these conditions were met. However, under Milliman Care Guidelines, Observation Care is indicated for all of the following: 

1)	Clinical care (eg, testing, monitoring, or treatment) needed beyond the usual emergency department time frame (eg, 3 to 4 hours) 
2)	Clinical care needed is not appropriate for a lower level of care (ie, discharge to outpatient setting not appropriate). 
3)	Patient has clinical condition for which observation care is needed, as indicated by: Other condition or finding (eg, laboratory test, imaging study, sign, symptom) that suggests a need for continued care, as indicated by 1 or more of the following (among others not relevant to this case):
o	Acute need to establish diagnosis (eg, repeat or continued testing or clinical assessments are needed.

With respect to Neonatology none of the conditions listed in the hospital's response were met. Specifically, there was no "severe respiratory abnormality that persists after emergency or observation level care" and there was no "abnormal respiratory sign or imaging that required intervention or caused, decreased level of alertness, lethargy, or cyanosis.  

Of note, this was the third admission within the first eleven days of life for this patient. It is unclear as to why testing, monitoring, and consultations were not or could not have been completed during the second hospitalization. Additionally, home monitoring with event recording, if necessary, could have been arranged before discharge, possibly averting a need for the third hospital stay. 

Therefore, there is no medical justification for a full in-patient admission. However, in view of the judgment of the primary doctor that additional monitoring and consultation was necessary, placement in observation for short-term monitoring was reasonable.

The health plan acted reasonably, with sound judgement and in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is upheld. Medical necessity is not substantiated.