Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hypothermia 

Treatment: Inpatient Hospital Admission Nursey- Newborn (Neonatal Intensive Care Unit (NICU) Level 2).

The insurer denied coverage for inpatient Hospital Admission Nursey- Newborn (Neonatal Intensive Care Unit (NICU) Level 2).

The denial is modified.

This was patient was born at 35 weeks gestation and had a birth weight of 2230 grams.  The patient was born via spontaneous vaginal delivery with Apgars of 9 and 9 at one and five minutes, respectively. Intrapartum history included new findings of oligohydramnios by ultrasound. Maternal treatment included penicillin 3 hours prior to delivery and a dose of betamethasone. Following delivery, the infant was allowed to bond skin-to-skin with their mother. The patient was transferred and admitted to the Neonatal Intensive Care Unit (NICU) at 30 minutes old at risk for hypothermia and hypoglycemia due to prematurity. The patient was placed on continuous cardiorespiratory monitoring. The initial glucose was 49 milligrams (mg) /deciliter (dL) (normal). The patient was started on ad lib feeds of Enfacare 22 calories/ounce. Lab work was unremarkable.  Initial care included placement on a radiant warmer to maintain normal body temperature.  The next day, the patient was placed in an open crib. Subsequently, due to a low temperature, the patient was placed back on a radiant warmer, but was placed again in an open crib later that day in which the patient remained until discharge.     
 
By virtue of prematurity, this infant was at risk for hypothermia. Admission to the NICU at Level II was in accord with the standard of care.  After placement in an open crib (from a radiant warmer), there was a brief interlude of low temperature necessitating rewarming. Then, at approximately 32 hours-old, the infant was placed back in an open crib and thereafter was able to maintain the patient's temperature in a normal range. The payer denied admission to the NICU citing Milliman Care Guidelines (MCG) 26th Edition Prematurity (Greater Than 1000 grams and greater than 28 weeks gestation, P-358) and Anthem CG-MED-26 Neonatal Levels of Care. The provider appealed stating that the patient required a radiant warmer for maintaining their temperature and that the patient was able to maintain their temperature for 48 hours prior to discharge. It cited MCG 27th Edition Neonatal Facility Levels of Care: Level II Special Care Nursery is indicated for neonate requiring 1 or more of the following: Premature birth at least 32 weeks gestation and weighing at least 1500 grams with physiologic immaturity as indicated by 1 or more of the following: Unstable body temperature (interventions needed to keep temperature (greater than) >97.7)".  

Thus, admission to the NICU for Level II care was in accord with MCG's guideline which was active at the time of the infant's birth.  Then, at issue is how long was Level II care necessary.  The provider maintains that > 48 hours of stable temperature in an open crib was required before discharge.  However, the same guideline cited by the provider allows for discharge from Level II to Level I "for stable and improved condition but requiring Level I Care while awaiting resolution of specific issues."  Therefore, at a certain point, Level II care was no longer needed, but continuing hospitalization to ensure normal body temperature was maintained in an open crib was reasonable. 

The denial is modified for the inpatient Hospital Admission (Neonatal Facility, Level II) is medical necessary for the first two days, and the remaining days are upheld at the Neonatal Facility, Level I.