Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Physiologic Jaundice. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 
	
The denial is upheld. 

This patient is a male born at 38 weeks of gestational via normal spontaneous vaginal delivery (NSVD) without complication, discharged on day 2 of life. Neonatal hyperbilirubinemia was noted prior to discharge with a 44-hour bilirubin of 11.1 mg/dL, and the patient was given follow-up within 48-hours. On day 3 of life, the patient's parents noted the patient's worsening jaundice, lethargy and decreased wet diapers.  The patient via the ambulance was taken to for evaluation and treatment. The patient's vital signs on arrival were notable for heart rate of 128, respiratory rate of 38, afebrile and room air oxygen saturation of 100%. Admitting weight was 3.148 kilograms. The patient's physical exam showed an awake, alert, well-nourished, well-appearing jaundiced patient in no acute distress. The patient's capillary refill was < 2 seconds. The patient's lungs were clear. The patient's cardiac exam was unremarkable. The patient's abdominal exam was soft with no associated tenderness, guarding, organomegaly, distension, rebound, or masses. The decision to admit the patient occurred before any evaluation was performed.  Sodium 144, potassium 4.6, blood urea nitrogen (BUN) 14, creatinine <0.2, chloride 107, bicarbonate 22, glucose ~80s, white blood cell count 11 without a left shift, hemoglobin 14.4, platelets clumped and bilirubin total 15.7/indirect 15.2. No imaging was performed. No urinalysis was submitted for review. The patient was admitted for double bilirubin lights. No intravenous fluids were administered. The patient was seen by a lactation counselor and was offered formula supplementation that he tolerated well. The patient's heart rate (HR) ranged from 123-148 (HR of 123 at discharge) and his respiratory rate (RR) ranged from 38-40 (RR of 38 at discharge). The patient's bilirubin was total 13.1/indirect 12.5 and the patient's bilirubin was total 10.8/indirect 10.2. No other diagnostic testing was performed. The patient was discharged later discharged. 

Based on the review of the medical record, this patient appears to have physiologic jaundice exacerbated by mild dehydration related to inadequate breast feed volumes. In a review of the management of indirect hyperbilirubinemia in term infants from UptoDate the authors note the following: Newborn infants are at risk for elevated total serum or plasma bilirubin (TB) levels. Term and late preterm infants (gestational age >=35 weeks) with a TB >25 mg/dL (428 micromol/L) or "severe" hyperbilirubinemia are at risk for developing bilirubin-induced neurologic dysfunction (BIND). 

The Bhutani nomogram is included for review and suggested that this patient's peak total bilirubin of 15.7 falls below the 95th percentile for age. This level alone is not sufficient to deem a patient at risk and the presence of other conditions would suggest the need for intervention. 

According to medical record and literature, inpatient hospital admission was not medically necessary for this patient. The patient was at low risk of significant indirect hyperbilirubinemia, and the patient received bilirubin lights below recommended standards for initiation. The patient's care could have been achieved by addressing parenteral apprehension, formula supplementation, counseling regarding effective breast feeding and with close follow-up. The admission was therefore not medically necessary as suggested by the insurer. 

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

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