Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Encounter for newborn examination; intrauterine growth restriction.
Treatment: Inpatient Neonatal Intensive Care Unit (ICU) Admission.
The insurer denied: Inpatient Neonatal Intensive Care Unit (ICU) Admission.
The denial is upheld.

The patient is a female infant born at 37 4/7 weeks with a birth weight of four pounds and 12.6 ounces. The infant was born via cesarean section to an adult gravida 3 para 1-0-1-1 due to non-reassuring fetal heart tones. The patient's mother had a history of lupus. The mother had prenatal care, her blood type was O+, and rapid plasma reagin (RPR) was non-reactive. Human immunodeficiency virus (HIV) was negative, hepatitis B surface antigen (HBsAg) was negative, and the patient was rubella immune. Group B streptococcus (GBS) was negative and COVID was negative. The mother was induced due to intrauterine growth restriction (IUGR). The infant was admitted to the neonatal intensive care unit (NICU) due to intrauterine growth restriction affecting care of the infant. The infant's Apgar scores were nine and nine at one and five minutes. The infant was on room air. The infant was initially placed under a radiant warmer. The infant was admitted to the stepdown unit of the neonatal intensive care unit. Echocardiogram was done and showed normal anatomy and function. The infant has an initial blood sugar of 73 milligrams per deciliter. On day two, the infant was on room air. She was taking oral feedings ad lib (as desired). The weight was 2171 grams. The infant was in an open crib, feeding well. Her platelet count was 309,000 and calcium was 8.9. On the third day, the infant was discharged to home.
The reason for prior denial is stated as: "The request tells us you went to the hospital because of need to be in the intensive care unit (neonatal intensive care unit). The plan clinical criteria considers a full hospital admission medically necessary when severe problems exist. The information we have does not show you have severe problems. For this reason, the request for full admission is denied as not medically necessary. It may help your doctor to know that we reviewed this request using the MCG (Milliman Care Guideline) guideline as modified by your plan called Newborn Care, Term, with Severe Illness or Abnormality (ORG: W0106)."
The reason for appeal is stated in a letter which states: "[A]fter careful review of the patient's medical record, there is indeed documentation of medical necessity that justifies inpatient confinement in an acute care facility. This NICU admission was medically necessary based on the clinical presentation and clinical findings for IUGR, low birthweight and maternal history of lupus. JHMC respectfully disagrees with the denial of our claim for provided inpatient services. 
This patient demonstrated a severity of illness, sufficient intensity of resources, and a medically necessary length of stay that were all consistent with the inpatient setting of care ordered by the attending physician and as such, this stay must be approved."

The neonatal intensive care unit (NICU) was not medically necessary as the patient could have been treated at a lower level of care with normal newborn care. The proposed treatment was medically necessary at newborn level of care. Per the attached criteria, Milliman Care Guidelines Health Inpatient and Surgical Care 25th Edition Newborn Care, Term, with Severe Illness, or Abnormality ORG: W0106(ISC), the patient is a growth restricted infant born to a mother with systemic lupus and positive antibodies. The mother has a condition that may affect the newborn. It was medically necessary to evaluate the infant for potential effects on the newborn from the maternal lupus. However, the testing/evaluation this patient underwent could have been done with normal routine newborn care at a lower level of care than the neonatal intensive care unit. The infant was feeding as desired, on room air, and not requiring tube feeds.