Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal reflux with a possible laryngospasm leading to a Brief resolved unexplained event (BRUE)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male with a past medical history notable for full term gestation delivered vaginally with a birth weight of 3430 grams without complications. Since birth, the child has been vomiting after feeds with coughing/choking that resolve spontaneously within 30 seconds. The episodes usually occur when picking up the child after a feed. These episodes have led to multiple Pediatrician visits and multiple formula changes (Enfamil to Gentlease to Neocate). On a particular date the patient had a similar episode that seemed to last longer (between 30 - 120 seconds - unclear from the documentation), witnessed by his father associated with cyanosis and apnea. The child never changed consciousness during the episode. There was no associated fever, weight loss, dehydration, bleeding or respiratory distress. The patient arrived by ambulance to the Emergency Department. The patient's vitals on arrival were notable for a heart rate of 158, a temperature of 99.5F, a respiratory rate of 56, a blood pressure of 77/53, and a room air oxygen saturation of 99%. His admitting weight was 3.4 kilograms and his height was 55 centimeters. His physical exam was notable for a well-developed, well-nourished male in no apparent distress. He appeared minimally jaundice. He had moist mucus membranes, normal capillary refill and warm, dry skin. His lungs were clear. His cardiac exam was unremarkable. His abdominal exam was notable for normal bowel sounds and was soft. He was observed without event and discharged home for outpatient follow-up. The insurer is denying the acute inpatient admission. This patient appeared to have gastroesophageal reflux with a possible laryngospasm leading to a BRUE. His exam, chest x-ray and EKG were unremarkable and he was monitored for several feeds prior to admission without recurrent symptoms. 

According to a review of acute events in infancy including brief resolved unexplained event (BRUE) from UptoDate the authors state the following:  
Brief resolved unexplained event (BRUE)

Clinical features include one or more of the following features:
1)	Cyanosis or pallor
2)	Absent, decreased, or irregular breathing
3)	Marked change in tone (hyper- or hypotonia)
4)	Altered level of responsiveness

The term should be applied only when the infant is asymptomatic on presentation and when there is no explanation for the episode after a focused history and physical examination. The estimated duration of the event is usually less than one minute (and typically <20 to 30 seconds).

For this patient, he did not technically meet criteria for low-risk BRUE given his age. However, he did not demonstrate any of the warning signs by the above criteria. His symptoms mostly fit gastroesophageal reflux with laryngospasm as suspected by the Emergency Department staff. Despite observation for nearly 10 hours in the Emergency Department, only a partial initial evaluation was performed with the remaining occurring after admission, including treatment for suspected gastroesophageal reflux disease (GERD).  A period of additional observation did not add anything to the safe management of this child and was performed more for other issues rather than medical necessity. 

The acute care admission was not warranted for clear GERD and treatment could have safely been initiated as an outpatient with follow-up by his Pediatrician. 

Uphold the denial of coverage for acute inpatient hospital admission. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.