Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastric Reflux.

Treatment: Inpatient admission.

The insurer denied the inpatient admission. 

The denial was upheld.

This is a female patient who presented to the Emergency Room (ER) having difficulty breathing. The patient had been sneezing and having nasal congestion for several days.  The patient's mother indicated that the patient was having breathing and feeding difficulties since birth. She had been to the pediatrician several times to evaluate the problem with no treatment rendered.  The mother indicated that there was increased work of breathing during feedings and occasionally the infant's face would turn red. A physical examination revealed adequate wet diapers and documented weight gain. Testing for respiratory syncytial virus (RSV) and influenza virus were negative.  The baby was observed to feed well with no vomiting. Ear Nose & Throat (ENT) were consulted and performed a nasal endoscopy; with normal results.  The diagnosis was reflux and the plan was to discharge the baby with treatment with lansoprazole; the mother refused discharge. The patient was medically stable and discharged home with outpatient follow-up.


According to UpToDate: Acute events in infancy including brief resolved unexplained event (BRUE):
"INTRODUCTION - Infants who present with a history of an acute event (an unexpected change in an infant's breathing, appearance, or behavior), reported by their parent or caregiver, represent a heterogeneous group of patients of varying ages with diverse pathophysiology. It is not a specific diagnosis, but rather a "chief complaint" that brings an infant to medical attention. The clinical challenge is to identify the infants who may benefit from further testing and prolonged observation, based on factors that suggest an identifiable underlying diagnosis or risk for subsequent events, while avoiding unnecessary testing, monitoring, and hospital admission for the many other infants without these characteristics. 
Brief resolved unexplained event (BRUE) - BRUE is not a specific diagnosis but a description of a sudden, brief, and now resolved episode in an infant that includes one or more of the following features: 
1) 	Cyanosis or pallor
2) 	Absent, decreased, or irregular breathing
3)	Marked change in tone (hyper- or hypotonia)
4)	Altered level of responsiveness
The term should be applied only when the infant is asymptomatic on presentation, and when there is no explanation for the episode after a focused history and physical examination. The estimated duration of the event is usually less than one minute (and typically <20 to 30 seconds). 
Low risk BRUE - Infants who have experienced BRUE are considered low risk if they have all of the following:
1)	Age >60 days
2)	Gestational age >=32 weeks and postconceptional age >=45 weeks
3)	Occurrence of only one BRUE (no prior BRUE, and BRUE did not occur in clusters)
4)	Duration of BRUE <1 minute
5)	No cardiopulmonary resuscitation (CPR) by a trained medical provider was required
6)	No concerning historical features
7)	No concerning physical examination findings

According to UpToDate: Apparent life-threatening event in infants:

"INTRODUCTION - An apparent life-threatening event (ALTE) describes an acute, unexpected change in an infant's breathing, appearance, or behavior that is frightening to the parent or caretaker. It is not a specific diagnosis, but rather a "chief complaint" that brings an infant to medical attention. The term ALTE and its definition were established at a consensus conference in 1986.  ALTE replaced misleading terms, such as "near-miss SIDS" or "aborted crib deaths", which incorrectly implied a direct association between these symptoms and SIDS.

The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.