Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth/Other/Single Liveborn Infant - Born Outside Hospital
Treatment: Inpatient Hospital

Diagnosis: Pregnancy/Childbirth/Other/Single Liveborn Infant - Born Outside Hospital
Treatment: Inpatient Hospital Admission: Neonatal Intensive Care Unit
The health plan denied the requested inpatient hospital admission as not medically necessary.

 The health plan's determination is upheld.

The male patient was born at 39 weeks estimated gestational age to a primigravida. The mother had prenatal care and prenatal serologies were negative with the exception of Group B Streptococcus being positive.
The neonate was born at home and delivered while the mother was on the toilet and may have fallen onto the bathroom floor. The mother reported that the infant had a spontaneous cry. On admission, his temperature was 97.3F degrees, with a hematocrit of 29, and platelets of 194. A magnetic resonance imaging (MRI) showed a small parietal scalp hematoma. The infant's blood glucose was 72. The infant was admitted to the Neonatal Intensive Care Unit secondary to "extramural birth and hypothermia." He was admitted for monitoring and management.
The neonate was monitored with continuous cardiorespiratory monitoring and pulse oximetry. His initial temperature improved after initial use of an open warmer bed under radiant heat. The hematocrit remained stable. He was hemodynamically stable throughout the admission and was ad lib feeding. The infant was discharged in stable condition with follow-up arranged.
 At issue is the medical necessity for the requested health service/treatment of Inpatient Hospital Admission: Neonatal Intensive Care Unit.

I uphold, in full, the health plan's determination of medical necessity.

No, the requested health service/treatment of Inpatient Hospital Admission: Neonatal Intensive Care Unit (NICU) was not medically necessary for this patient.
After initial temperature stabilization, the infant received normal/routine newborn infant care. None of the services provided required NICU Level of Care. Monitoring of vital signs could have been performed at a level of care that was not Neonatal Intensive Care Level of Care.
Per the health plan guidelines used (Milliman Care Guidelines (MCG)), the following are necessary for admission to the Neonatal Intensive Care Unit: 
1)hemodynamic instability
2)low birth weight
3)electrolyte abnormalities
4)severe infection
5)abnormalities of the kidneys
6)abnormalities of the central nervous system (seizures)
7)no active bleeding
8)need for respiratory support (mechanical ventilation)
9)require surgical repair of complex congenital or acquired condition
10)need urgent pediatric medical or surgical subspecialist care
11)require extreme support services such as high frequency ventilation, extracorporeal membrane oxygenation, nitric oxide administration, hypothermia therapy, dialysis, or perioperative care for surgery for severe defects or conditions.

Because the patient did not meet any of the criteria for Admission to the Neonatal Intensive Care Unit, care at this level was not medically necessary.
Specifically, it was not medically necessary for this neonate to be cared for at the Neonatal Intensive Care Unit level of care. The patient did not have any apnea/bradycardia, did not have problems with feeding, did not receive a blood transfusion, and was not treated with intravenous medications (antibiotics, inotropes). The patient received routine newborn care and monitoring.