Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hyperbilirubinemia.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned.

The patient presented for a bilirubin recheck.  She required phototherapy for hyperbilirubinemia during the initial nursery stay.  She went back to her primary care physician (PCP) for follow-up and was told to return for another bilirubin check.  Her mother reported that the patient "sleeps all the time".  She is fed every 2 hours.  The patient is receiving expressed breast milk via bottle.  Her mother states that the patient has been eating well with multiple bowel movements.  The mother felt that her eyes looked yellow.  A registered nurse (RN) also documented in the emergency room (ER) that the mother stated the patient was more difficult to wake than normal and slow to feed.  The ER physician documented "complicated post-delivery course which included septic workup secondary to possible chorioamnionitis".  Vital signs in the ER revealed a temperature of 97 degrees Fahrenheit, oxygen saturation (O2 sat) 99%, and heart rate (HR) 150.  The physical exam was unremarkable.  Per the ER physician, they were unable to obtain all specimens, and it was then brought to their attention that the patient was supposed to proceed directly to the nursery unit for a lab draw there.  The total bilirubin returned 16.5, so the child was readmitted for phototherapy and poor feeding.  The patient is of Cambodian heritage and has a first cousin with glucose-6-phosphate dehydrogenase (G6PD).  The birth weight for the infant was 3120 grams (gm).  The bilirubin was noted to be 16.5 at 127 hours of life with the rate of rise calculated at 0.17.  The level was in the high intermediate risk zone.  The patient had 8% weight loss since birth.  The admitting documents described the child to be icteric to the groin.  She was treated with phototherapy and feeds via bottle and discharged the following day. 

At issue is the medical necessity of an inpatient level of care.

The requested Inpatient hospital admission was medically necessary for this patient.  She presented with 8% weight loss since birth, her mother was complaining she was more difficult to wake, slow to feed and of hyperbilirubinemia.  Based on risk stratification published by the American Academy of Pediatrics, this patient would classify as a high risk infant with "exclusive breastfeeding, particularly if nursing not going well and weight loss is excessive."  Given her age and risk factors, the threshold for the commencement of phototherapy would be 15.  Her level was 16.5 at 127 hours of life.  For a patient with risk factors making her high risk in addition to bilirubin levels in the high intermediate risk zone based on risk assessment algorithms published by the American Academy of Pediatrics, admission for intense phototherapy and close monitoring is in the best interest of the patient and is medically necessary.  Given the main complication of uncontrolled bilirubin levels is neurologic dysfunction, admission for intense phototherapy and monitoring would be in the best interest of the patient.  Also, with intensive phototherapy it is important to monitor the neonate's hydration status as well as body temperature.  These infants are at risk for hyperthermia and excessive weight loss.  Exaggerated hyperbilirubinemia can also be a sign of sepsis.  Monitoring for sepsis is also necessary.  For these reasons, inpatient hospital stay was medically necessary for this patient.