Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Infection (suspected neonatal sepsis).
Treatment:  Continued Inpatient Hospital Admission.

The insurer denied the Continued Inpatient Hospital Admission.  The denial is upheld.

The male patient was born 3 weeks early via spontaneous vaginal delivery with rupture of membranes one to two hours before delivery. Apgar scores were eight at one minute and nine at five minutes. The birth weight was 3685 grams. He did well the first 24 hours after birth, except for failed critical congenital heart disease (CCHD) screen due to hypoxia noted on pulse oximetry. He eventually passed but subsequently developed respiratory distress with persistent oxygen requirement. His exam at that time was significant for mild intercostal retractions, grade II holosystolic murmur, sacral dimple with a difficult-to-visualize base, and jaundice to the lower extremities. He was subsequently transferred to the neonatal intensive care unit (NICU) for further management, with concern for possible sepsis. The diagnosis for the infant was presumed sepsis (despite negative blood cultures), unable to rule out meningitis. Feedings were started, working up to one ounce of expressed breast milk every three hours or breastfeeding. He was able to wean off all respiratory support by 48 hours, so was given the diagnosis of transient tachypnea of the newborn. The patient was transferred to the pediatric floor to continue his course of antibiotics. 

The continued inpatient hospital admission was not medically necessary.

Group B streptococcus infection (GBS) is a significant cause of early-onset neonatal sepsis as well as late-onset sepsis in infants. The institution of intrapartum antibiotics was established to decrease the incidence of early-onset sepsis. There is no effective prevention of late-onset disease. Guidelines for prevention were initially published by the Centers for Disease Control and Prevention (CDC) in 1996 and are updated as new information or research become available. Early-onset disease presents within the first 12 to 24 hours, often with non-specific symptoms such as respiratory distress, fever, poor feeding, jaundice, tachycardia. Antibiotic therapy includes ampicillin and gentamicin as the primary agents for neonates. If bacteremia is present, the treatment course is ten days (14 days for uncomplicated meningitis). Because of the possibility of significant morbidity or even mortality of untreated early-onset group B streptococcus (GBS) sepsis, the duration of therapy in culture-negative situations is a bit tricky. 

According to the latest recommendations, "unless there is a strong clinical or biochemical indication to prolong antibiotics physician[s] need to trust the culture results and to stop antibiotics for suspected sepsis within 36-48h rigorous evaluation of clinical symptoms ("organ dysfunction") over 36-48h in combination with appropriately selected biomarkers ("dysregulated host response") may be used to support or refute a sepsis diagnosis." (2) 

Based on the documentation submitted, this infant was born at term to a mother with initially unknown group B streptococcus (GBS) status. The baby was doing well and then developed respiratory distress and hypoxia. Sepsis was suspected, and then with the group B streptococcus (GBS) information it was presumed. The patient was treated with appropriate antibiotics, with negative cultures. His distress resolved within 48 hours, and he was eventually given a diagnosis of transient tachypnea of the newborn, a relatively benign condition. At the time the patient was transferred to the pediatric floor on, he was stable. His hyperbilirubinemia was also resolving. Based on this information and the current guidelines, the three days in question were not medically necessary or appropriate. There were no other clinical situations or complications that would have justified these days.