Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Small for gestational age with low initial serum glucose
Treatment: Neonatal Intensive Care Unit admission
The health plan denied the requested Neonatal Intensive Care Unit admission as not medically necessary.
The health plan's determination is upheld.

The patient was born by vaginal delivery at 37 weeks' estimated gestational age. Her mother was a primigravida whose pregnancy was complicated by gestation hypertension requiring Nifedipine and Labetalol throughout the pregnancy. The patient weighed 2041 grams (4 pounds 8 ounces), and the Apgar scores were 9 at both one and five minutes of life. The infant was taken to the Neonatal Intensive Care Unit (NICU) for "observation and management of weight." The infant was described as small for gestational age (SGA).

Diagnoses included: full term, singleton, intrauterine growth restricted, hyperbilirubinemia, capillary hemangioma on left leg, and newborn with feeding problems. The infant was discharged to home. Follow-up care was arranged.

At issue is the medical necessity for the requested health service/treatment of the neonatal intensive care unit. I uphold, in whole, the health plan's determination of medical necessity.

It was not medically necessary for the patient to be admitted to the NICU, as the infant did not meet the plan criteria for admission to the Neonatal Intensive Care Unit on the dates of service. Per the Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 26th Edition, inpatient admission is indicated for hypoglycemia. However, the patient did not have hypoglycemia per either the American Academy of Pediatrics (AAP) or the Pediatric Endocrine Society guidelines. Per the AAP guidelines, hypoglycemia in an asymptomatic infant is a glucose < 25 milligrams/deciliter (mg/dL) (birth to 4 hours of life) and < 35 mg/dL (>4 hours of age to 24 hours of age).

The patient was asymptomatic, and the lowest documented glucose was 60 mg/dL. The use of intravenous (IV) glucose is not the standard of care in management of neonates who do not have documented hypoglycemia. Although the infant was treated with IV glucose and was cared for in the NICU, the standard of care is not management with IV glucose for an asymptomatic infant whose glucose is >45 mg/dL in the initial 24 hours.

The infant was small for gestational age and meets established criteria for glucose monitoring. [AAP guideline]. However, the infant's initial glucose was 60 mg/dL and intravenous fluids were initiated. The infant's glucose concentration did not meet established criteria for the definition of hypoglycemia and the concentration did not meet criteria for the treatment with intravenous fluids. First line treatments for hypoglycemia include: 1) early initiation of feeding and 2) Dextrose gel 200 milligrams/kilogram (mg/kg) massaged into the buccal mucosa (This is an effective treatment alternative in asymptomatic late preterm and term infants).

Per the American Academy of Pediatrics (AAP) guidelines, from birth to 4 hours of age, intravenous glucose is only indicated in the asymptomatic infant if the glucose is < 25 mg/dL. From 4 hours to 24 hours intravenous (IV) glucose is only indicated if the glucose is < 35 mg/dL. The infant could have been monitored at an alternate level of care. Care in the Neonatal Intensive Care Unit was not medically necessary. If the medical providers routinely admit small for gestational age infants to the NICU for observation, the level of care would still only meet the criteria for well newborn nursery/general nursery care, regardless of where the care is provided.

Because the neonate did not have hypoglycemia and did not meet the Milliman Care Guidelines (MCG) criteria for NICU admission, the requested health service/treatment of neonatal intensive care unit was not medically necessary for this patient.