Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neonatal Jaundice
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who was born at home by spontaneous vaginal delivery. Maternal Group B Streptococcus status was unknown. The patient was brought to the Emergency Department for evaluation and management. She was noted to be hypothermic, which resolved after being placed under a radiant warmer. Her birth weight was 2.785 kilograms, and Apgar scores were 7 at one-minute and 9 at five-minutes of age. The patient was initially admitted to the well newborn nursery for routine care. However, she was then transferred to the Neonatal Intensive Care Unit (NICU) for triple phototherapy for a total serum bilirubin (TSB) of 11 milligrams per deciliter (mg/dL).
She was hemodynamically stable and a well appearing infant. Erythromycin and Vitamin K were administered. Laboratory testing included glucose screening, a complete blood count, and liver function studies. A blood culture was obtained at admission. Routine newborn care was to be provided.
She was hemodynamically stable and a well appearing infant. A hearing screen was performed. An infant metabolic screen was completed. A hepatitis B vaccine was administered. Routine newborn care was continued.
She was a hemodynamically stable and well appearing infant. A critical congenital heart disease screen was completed and passed. A total serum bilirubin was performed and was 11.0 milligrams per deciliter (mg/dL). The infant was transferred to the neonatal intensive-care unit (NICU) and her discharge was held. Triple phototherapy was initiated.
She was hemodynamically stable and a well appearing infant. A follow-up bilirubin was 9.6 mg/dL. A rebound bilirubin was scheduled for the afternoon. The patient was then discharged to home. She was breastfeeding/formula feeding well. The critical congenital heart disease screening and infant metabolic screening were completed. A newborn car seat evaluation was completed. The parent was to call for a follow-up appointment in 2-3 days after discharge. The discharge weight was 2.67 kilograms.
At issue is the medical necessity of an inpatient stay.

Yes. The inpatient stay was medically necessary. Inpatient stay for a well newborn delivered vaginally is medically necessary for 48 hours. Continued stay is supported by the Milliman Care Guidelines (MCG) Nursery Criteria for "neonatal jaundice requiring monitoring or phototherapy." Therefore, the patient met criteria for continued inpatient care.
The patient was a well newborn with no risk factors for hyperbilirubinemia other than a gestational age of 37.3 weeks. She was being evaluated for discharge, when the bilirubin prior to discharge was obtained and was noted to be 11 mg/dL. The patient was then transferred to the Neonatal Intensive-Care Unit (NICU) where phototherapy was initiated.
The bilirubin obtained met the 2004 American Academy of Pediatrics (AAP) Hyperbilirubinemia criteria for initiation/treatment with phototherapy, which were the current guidelines at the time of the neonate's birth. Per the AAP guideline, it is an option to provide inpatient treatment if the bilirubin is within 2-3 mg/dL of threshold. In this case, the bilirubin of 11 mg/dL was withing the 2-3 mg/dL of the phototherapy threshold (12 mg/dL). Therefore, inpatient care was medically necessary per the AAP guidelines.
The Milliman Care Guidelines (MCG) for Neonatal Jaundice are criteria for determining admission to the hospital or alternative care for a neonate after discharge from the hospital. The infant in this case had not been discharged. Therefore, the MCG Nursery Criteria would have been the appropriate set of criteria for this review. Using the MCG Nursery criteria, the infant would have met criteria for continued inpatient care for "neonatal jaundice requiring monitoring or phototherapy."