Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty Breathing
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient had been hospitalized in the neonatal intensive-care Unit (NICU) for two weeks for hypoglycemia and respiratory distress requiring continuous positive airway pressure (CPAP), also diagnosed with gastroesophageal reflux disease (GERD), now presenting with increased work of breathing, choking episodes, mottled skin, increased hypotonia. He was followed by multiple subspecialists, a with normal swallow study, normal echocardiogram, normal chest computed tomography (CT) scan in the NICU, family history of hypoglycemic ketonuria. Vital signs included a temperature of 36.7 degrees Celsius, heart rate 170, respiratory rate 24, blood pressure 106/49. Examination was significant for being alert and active, breathing with abdominal muscles, clear lungs, and moist mucous membranes. A chest x-ray was obtained revealing mild cardiomegaly and increased pulmonary vascularity.
He was admitted for evaluation of feeding difficulties, tachypnea, and progressive hypotonia. His family history was notable for 4p16.3 deletion with multiple siblings having motor delay, hypotonia, hypoglycemia. Admission orders included pulmonary and ear, nose, and throat (ENT) consultations, consideration for triple scope and sleep study, electrocardiogram, Lactation consultation, neurology consultation, speech language pathology (SLP) / occupational therapy (OT) / physical therapy consultations, genetics/metabolism consultations, suctioning as needed, discussion about vaccines, and breastfeeding ad lib. He was diagnosed with rhinovirus and his clinical course progressed with eventual resolution of his increased work of breathing and improvement in his congestion. Brain magnetic resonance imaging (MRI) was obtained and was normal, magnetic resonance (MR) spectroscopy was planned with sedation. An echocardiogram revealed a small patent foramen ovale of no clinical significance. He was discharged once he was no longer having episodes of choking or apnea, desaturations, or respiratory distress.
At issue is the medical necessity of an inpatient stay. 

Yes. The requested acute inpatient admission was medically necessary for this male infant with ongoing episodes of choking, desaturation, respiratory distress, and apnea until he was discharged. He could not have been safely discharged at an earlier date or managed at a lower level of care. 
 
This infant was admitted with progressive hypotonia compounded by acute respiratory viral infection resulting in apnea, desaturation, increased work of breathing, and choking. Treatment is generally supportive, including hydration, supplemental oxygen, and assisted ventilation when necessary. Bronchodilators are not typically recommended unless there is a strong family history of atopic disease. Antibacterial agents are not indicated. In this infant's case, there was a strong family history of 4p16.3 deletion associated with hypotonia, hypoglycemia, and motor delay. While the most likely cause of his progressive hypotonia, it was necessary to rule out other causes given some dysmorphic features.
In this case, it took the full duration of the hospital stay for his respiratory symptoms to resolve so that he could be safely discharged home. The full inpatient stay was medically necessary and appropriate.