Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperbilirubinemia
Treatment: Inpatient admission 
The insurer denied: Inpatient admission 
The denial is upheld

The patient is an infant male, a newborn male infant at the time of admission. Maternal blood type was O-positive, but no other prenatal information was provided. The infant's birthweight was not provided, nor were any other details of the pregnancy, the intrapartum or postpartum course. The infant was discharged on the day after birth, at which time he weighed 3.88 kg (kilogram). He was being breastfed. On the day of discharge his total bilirubin was measured and resulted at 5.8 mg/dl (milligrams per deciliter), as of 0858 hours (20 hours of life). Per the AAP (American Academy of Pediatrics) Hour Specific Nomogram for Hyperbilirubinemia (reference below), this fell into the "Low Intermediate Risk" zone. No follow-up was indicated at that time, for the bilirubin itself.
It can be inferred that the infant was seen by his primary pediatrician the day after discharge. No details of that encounter are provided, other than a measured total serum bilirubin (TSB) of 12.5 mg/dl (milligrams per deciliter). The time at which that value was obtained was not provided. Depending on the time that the value was obtained, the value would fall in the "High Intermediate Risk" zone per the above-referenced guideline; clinical follow-up in 48 hours would be recommended, with a remeasure as indicated.
On the second day post discharge, the infant presented to the Emergency Department of the admitting hospital for evaluation and possible treatment of hyperbilirubinemia. Total bilirubin was measured at 1645 hours, with a result of 17.8 mg/dl (milligrams per deciliter). This value falls in the "High Risk" zone of the above-referenced guideline, with follow-up recommended within 4 - 24 hours. As no other medical issues were known or identified at the time of evaluation, this infant was considered "low risk" as per nomogram guidelines, and phototherapy was recommended to be initiated at a level of 18.0 mg/dl (milligrams per deciliter).
Per the hospital records, the patient was admitted and aggressively treated with phototherapy. A variety of other medical tests and interventions were also undertaken. The patient was discharged the following day after a marked decline in his TSB (total serum bilirubin).

The inpatient admission was not medically necessary.
The records provided do not include a birthweight. 
Without the required information, it cannot be determined if there were factors that would have classified this infant as "medium risk" per the nomogram. As the nomogram indicates phototherapy to be initiated at 18.0 mg/dl (milligrams per deciliter), and this infant's measured at 17.8 mg/dl (milligrams per deciliter), admission for inpatient therapy of the hyperbilirubinemia is not recommended.

The infant was admitted for the treatment of hyperbilirubinemia, the standard for which is guided by the AAP (American Academy of Pediatrics) Hour Specific Nomogram for Hyperbilirubinemia. Should he have fallen the "intermediate risk" range, initiation of phototherapy at 15.8 mg/dl (milligrams per deciliters) would have been indicated. Factors needed to accurately assess infant's "risk level" include his hydration status, e.g. birth weight, admit weight, description of feeding pattern, voiding, stooling, mother's lactation status, etc. Not all of these are provided.