Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Preterm Newborn

Treatment: full hospital admission 

The insurer denied coverage for the full hospital admission.

The denial is overturned.

This infant born prematurely, birth weight 2021 grams via Cesarian section to a mother with preeclampsia complicated by severe features requiring magnesium sulfate (1 dose) and corticosteroids (2 doses).  Apgars (appearance, pulse, grimace, activity and respiration) were 9 and 9 at 1 and 5 minutes, respectively.   Upon admission to the neonatal intensive care unit (NICU), there was continuous cardiorespiratory monitoring including pulse oximetry. Contrary to the provider's assessment, there was no tachycardia or tachypnea. Vital signs were normal for age. The lungs were clear.  An arterial blood gas (in room air) was normal for age, including a base excess of -5.4. Glucose of 66 was normal (not borderline as stated by the provider).  A complete blood count (CBC) was normal. A blood culture was done (ultimately, no growth).  Contrary to the provider's assessment, there was no tachycardia or tachypnea. Initial diagnoses of transient tachypnea of newborn (TTN) and metabolic acidosis were not supported by physical examination or laboratory results. The initial plan included intravenous (IV) Dextrose 10 at 80 milliliters per kilogram per day (mls/kg/day) and to start feeding. After initial stabilization, thermal neutrality was maintained in an incubator.   The following day, the infant remained well, in room air, in an incubator, with IV Dextrose10 at 80mls/24 hours and with oral (p.o.) feeds (breast/formula).  Glucose was normal. The next day, feeding was advanced, and IV fluid was discontinued.  Thermal regulation was via an incubator. Glucose was normal. The following day, the infant remained well in room air and was in a crib. Glucose was normal. A transcutaneous bilirubin was 8.7 at 60 hours. No treatment was needed. Discharge planning was started with a requirement for a stale temperature out of an incubator for greater than 24 hours. Four days after admission, the infant was discharged with a plan to see the primary Pediatrician in 24 hours.

According to Milliman care guidelines (MCG): P-358, admission is indicated for premature delivery. 

Although this infant did very well (there was no hypoglycemia, significant metabolic acidosis, or TTN), admission to a NICU, and not a well-baby nursery, was medically necessary.  Care was in accord with the 5 Stages laid out in this guideline and consistent with criteria in MCG: level of care (LOC)-005, Neonatal Facility, Level II.  Cardiorespiratory monitoring was indicated for the risk of apnea of prematurity. IV fluid was necessary to ensure adequate hydration and a normal glucose until p.o. feeding was sufficient.  An incubator was needed to maintain thermal neutrality until the day prior to discharge.  Also, the expected nursing ratio of 1:3 to 1:4 exceeded the ratio in most well-newborn (general) nurseries.   

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.