Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Premature, low birth weight, respiratory failure, pulmonary hypertension.
Treatment:  Continued Inpatient Rehabilitation Admission.

The insurer denied the continued Inpatient Rehabilitation Admission.  The denial is overturned.

The patient is a toddler-aged male child with complex medical history significant for extremely premature birth at 23 weeks' gestation with birth weight 440g (grams), severe bronchopulmonary dysplasia with chronic lung disease status post tracheostomy placement weaned from mechanical ventilation, pulmonary hypertension treated with sildenafil, feeding difficulty status post gastrostomy tube placement, intractable seizure disorder with recent acute hospitalization due to deep desaturations (increased clonazepam and lacosamide), amniotic band syndrome with leg length asymmetry and chronic wound and possible need for skin graft, mild ventriculomegaly with periventricular leukomalacia, central vision impairment with resolved retinopathy of prematurity following laser ablation, hearing deficit with abnormal middle ear function, eczema and cow's milk sensitivity, history of right submandibular abscess, hip dysplasia, and possible connective tissue disorder. He was readmitted to the rehabilitation hospital after acute ICU (intensive care unit) admission for increased seizure activity to continue acute care rehabilitation services. 

The Continued Inpatient Rehabilitation Admission was medically necessary.

This young male child was born at the cusp of viability at 23 weeks' gestation. He experienced multiple complications as a result of and in addition to his extreme prematurity, affecting the majority of his organ systems (respiratory, neurologic, gastrointestinal, cardiac, sensory including vision and hearing, orthopedic, and immune). He returned to Blythedale Children's Hospital after acute hospitalization for worsening seizures associated with deep desaturations. With optimization of lacosamide along with three other anticonvulsants, he has stabilized with no clinical seizures. He continues to require ventilatory support with BiPAP (bi-level positive airway pressure) but has been working on PMV (prolonged mechanical ventilation) trials. He receives all nutrition and fluids via gastrostomy but continues to have issues with vomiting requiring periods of Pedialyte hydration. He has a chronic wound on his left lower extremity that is followed closely by orthopedic surgery and has been slowly and steadily granulating, so far avoiding a skin graft. He is followed closely by ophthalmology for retinopathy of prematurity as well as otolaryngology for middle ear abnormalities. Discharging a fragile child with such a complicated history and complex medical needs requires coordination, education, and resources. This process is time consuming, but attention to detail ensures safe and successful discharge. The family was available at the bedside for teaching, and by the date of discharge, demonstrated competency in all areas. The two weeks in question were essential in preparing both the child and the family for safe discharge home. The requested dates through discharge were medically necessary and appropriate.