Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis

Treatment: Inpatient hospital admission 

The insurer denied coverage for an inpatient hospital admission. 
 
The denial is overturned.

This patient is an infant female who was delivered by vacuum-assisted vaginal delivery to a mother with history of gestational diabetes mellitus (DM) and hypertension with preterm, premature ruptured membranes for 69 hours prior to delivery. The mother was treated in labor with magnesium sulfate (MgSO4) for gestational hypertension in labor.

The Apgar scores at delivery were 4/8, the patient received blow-by oxygen (O2) in the delivery room, and had no significant respiratory distress after delivery, per Peds (pediatrics). The admission labs were remarkable for a white blood count of 33.3. Following delivery, she was noted to be pale and desaturating to the 80's on room air, and she was given blow by blow oxygen.

Immediately following delivery, the patient was admitted to the neonatal intensive care unit (NICU) for pallor and premature ruptured membranes at 69 hours. Her labs were notable for a white blood count of 33.3. The plan of care included rule out sepsis and follow up on cultures. Her complete blood count was benign, and her blood cultures were negative at 48 hours. The patient remained stable, and she was discharged. The patient met Milliman Care Guidelines (MCG) for inpatient hospital admission. The plan of care included presumed sepsis, with a need to follow up on cultures. Her complete blood count was benign, and her blood cultures were negative at 48 hours. 

Due to multiple comorbidities and signs of acute respiratory insufficiency, this infant deserved at the least 36-48 hours of high level and close clinical observation, a review of markers for sepsis, respiratory support until stable, and close clinical observation after low Apgar scores at birth. The infant did stabilize, but the events of labor placed the infant at extreme risk of post-delivery destabilization to multiple organ system dysfunction at or around the time of birth. Exposure to MgSO4 in utero further left this infant with a need for close observation due to multiple comorbidities at birth.      

"Fetal growth restriction (FGR) continues to be a leading cause of preventable stillbirth and poor neurodevelopmental outcomes in offspring, and furthermore is strongly associated with the obstetrical complications of iatrogenic preterm birth and pre-eclampsia." [Audette, M. C., & Kingdom, J. C. 2018]

"Pregnancy at advanced maternal age (age > [greater than] 35 years old) is considered a risk factor for adverse maternal and perinatal outcomes... Possible maternal complications of pregnancy at age 35 or older include increased risk of spontaneous miscarriage, preterm labor, gestational diabetes mellitus, pre-eclampsia, stillbirth, chromosomal abnormalities, and cesarean delivery. Possible adverse fetal outcomes include infants small for gestational age and intrauterine growth restrictions, low Apgar score, admission to neonatal intensive care units, and an autism spectrum disorder." [Glick, I., et al, 2021]                                                         

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for an inpatient hospital admission is overturned. Medical necessity is substantiated.