Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachypnea
Treatment: Continued stay in Pediatric Intensive Care/Neonatal Intensive Care
The insurer denied: Continued stay in Pediatric Intensive Care/ Neonatal Intensive Care
The denial is upheld

The patient is a female infant born 8 months ago. The infant was born at 37 5/7 weeks gestation. Her birthweight was 2,855 grams. The infant was delivered via cesarean section. The patient's mother is HIV (human immunodeficiency virus) positive since 2014, and RPR (rapid plasma regain) positive, and HSV2 (Herpes simplex virus type 2) positive. The infant was admitted to NICU (neonatal intensive care unit) after birth due to need for high flow nasal cannula at 3LPM (3 liters per minute), 21%. The infant was weaned to room air within a few hours. Ampicillin/Gentamicin were given for 48 hours. Zidovudine was started every 12 hours due to maternal HIV (human immunodeficiency virus) positivity. Baby blood was type O negative (DAT [direct antibody test] negative). The mother was GBS (Group B streptococcus) positive. The mother was on triple retroviral therapy during pregnancy. The NICU (neonatal intensive care unit) progress note documented weight 2755 grams on Day of life 2. Blood sugar in last 24 hours: 74-80mg/dL (milligrams per deciliter). On room air. Continue PO (oral) zidovudine. Infant feeding 30-40ml (milliliters) every 3 hours. Completing 48 hour rule out sepsis. Completing ampicillin and gentamicin IV (intravenous). Baby RPR (rapid plasma regain) NR (non-reactive), but cord reactive. Titer was 1:2 and just requires outpatient follow up. Mother treated appropriately.
On Day #2 the patient was discharged home. The health plan denied coverage of the inpatient admission, noting, "We have re-reviewed the specific circumstances and health condition as documented in the appeal and clinical information you provided to us. The reviewer is a health plan MD [medical doctor] who is board certified and specializes in Neonatal-Perinatal Medicine Pediatric. It's their recommendation that we keep our previous coverage decision. Here's why:
"Your patient went to the intensive care unit (pediatric intensive care unit or neonatal intensive care unit) for newborn care. Their doctor wants to extend their stay. The plan clinical criteria consider an extended stay in the intensive care unit (ICU) medically necessary when there are still severe problems such as breathing problems, feeding problems, or severe infection. The information we have does not show they had these or other severe problems. For this reason, the request for them to remain in the ICU [intensive care unit] is denied as not medically necessary but their hospital stay on Day #1 may be approved as General Nursery Level of care. It may help their doctor to know that we reviewed this request using the MCG guideline, as modified by your plan, called Newborn Care, Term, with Severe Illness or Abnormality (ORG.' W0106)."

The requested health service was not medically necessary.

The proposed treatment is not medically necessary. Treating this patient in the hospital is the appropriate path. While treating the patient was appropriate, NICU (neonatal intensive care unit) level of care was not medically necessary. The patient is a term infant who had initial respiratory symptoms that resolved quickly. A blood culture was obtained, and IV (intravenous) antibiotics given. The infant was feeding ad lib and awaiting culture results. Per the attached and cited guideline, treating this patient at the acute level at special care nursery level 1 is appropriate. The patient was asymptomatic finishing IV (intravenous) antibiotics and ad lib feeding on room air. The patient could have remained at Level 1 nursery or normal newborn nursery.