Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Trisomy 13; atrial septal defect

Treatment:  Acute inpatient hospital admission

The insurer denied coverage for acute inpatient hospital admission.  The denial was reversed.

This patient is a male with trisomy 13, an atrial septal defec,t and a bicuspid aortic valve, as well as branch pulmonary artery stenosis.  He has severe obstructive sleep apnea leading to placement of a tracheostomy tube.  He is ventilator dependent at night and uses a trach collar with oxygen during the daytime.  He is profoundly developmentally disabled, being dependent for all activities of daily living.  He has known tracheobronchomalacia.  He underwent bronchoscopy and ear tube placement under propofol and fentanyl sedation in early 2019.  He had a bronchoalveolar lavage that demonstrated multiple polymorphonuclear cells consistent with potential infection.  He was found to have a laryngeal cleft and peripheral bronchomalacia in addition to adenoid hypertrophy.  He was admitted because he developed a fever after bronchoscopy and was desaturating.  In the pediatric intensive care unit (PICU) he was placed on mechanical ventilation; his trach was changed from an uncuffed to a cuffed tracheostomy tube, and his home ventilator settings were sequentially increased.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  This patient had a fever and desaturation after bronchoscopy with bronchoalveolar lavage that showed multiple polymorphonuclear cells suggesting possible infection.  He required adjustments to his invasive ventilator settings due to hypercapnea and hypoxemia.  He was evaluated for potential sepsis and required continuous monitoring as a result.  His ventilator adjustments could not have safely occurred as an outpatient.     

This child was febrile and hypoxemic following bronchoscopy.  He is medically complex and had bronchoalveolar lavage findings consistent with potential infection that could have become systemic resulting in sepsis resulting from bronchoscopy and alveolar lavage.  He needed his invasive ventilator settings adjusted and needed a different tracheostomy tube in order to ensure adequate ventilation and oxygenation at home.  The complexity of this care is too great to perform in an outpatient setting.  Therefore, the acute inpatient hospital admission is considered medically necessary for this patient.

Per Moore PE; Boyer D; O'Connor MG; Baker CD; Rettig JS; Sterni L; Halbower A; Wilson KC; Thomson CC. (2016), "The child must demonstrate medical stability before discharge. The child's oxygen requirement and ventilator settings should remain unchanged during the days to weeks before being discharged...". Per Paulides, F.M., Plotz, F.B., Verweij-van den Oudenrijn, L.P. et al. (2012), "Over time, there was an impressive increase in the application of HMV in children. This increase was most obvious in the youngest age group with invasive HMV, and these children had very long stays in the PICU." Per Kneyber, M. et al. (2017), "We recommend achieving normal CO2 levels in children with normal lungs (strong agreement). For acute (non-)pulmonary children, higher levels of CO2 may be accepted unless specific disease conditions dictate otherwise...". Per Sterni LM, Collaco JM, Backer DC et al. (2016), "Collaborative generalist and subspecialist comanagement is the Medical Home model most likely to be successful for the care of children requiring chronic invasive ventilation...".

The denial of coverage is not reasonable because the complexity of care was too great to be performed in an outpatient setting. Use of the Milliman criteria for bronchoscopy fails to account for the other reasons why this child was admitted including need for ventilator adjustments, hypoxemia, hypotension, tachycardia and fever.

Based on the above, the medical necessity for the acute inpatient hospital admission is substantiated.  The insurer's denial is reversed.