Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Apnea, cyanosis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The male patient was born via Cesarean section secondary to breech presentation at term gestation. His mother's pregnancy was uncomplicated except for the diamniotic-dichorionic twin gestation. He was noted to be twin "B", and his Apgar scores were 9 at one and five-minutes of age. The patient's birth weight was 2600 grams. He was admitted to the well newborn nursery for routine newborn care.

At approximately 37 hours of age, he was noted to be cyanotic while sleeping. A parental report noted that he was "cyanotic and not breathing." He was transferred to the Neonatal Intensive Care Unit (NICU) for evaluation and monitoring. A chest x-ray showed questionable left basilar atelectasis. A blood culture was obtained, and a 48-hour sepsis evaluation was performed including the administration of ampicillin and gentamicin. During the NICU course, he was noted to have a desaturation to 76 percent (%) for 20 seconds, 87% (percent) for 12 seconds, and 66% (percent) for 15 seconds. All events occurred while sleeping but were around the time of feedings. Events were mostly self-limiting, and no intervention was required. One event occurred after choking and was associated with an emesis. No further events occurred after 12:30 pm. The patient was noted to be stable during the NICU admission. The infant was noted to have hypospadias, and a urology consult was obtained. The patient's bilirubin was monitored and remained below phototherapy level. The care plan was to discharge when the patient was free of significant events with feedings for 48 hours. Critical congenital heart disease screening was performed prior to discharge, and the infant passed. The infant was discharged to home.

At issue is the medical necessity of an inpatient hospital admission.
I uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.

The patient had completed a 48-hour sepsis observation period with treatment using antibiotics (ampicillin and gentamicin). The patient was hemodynamically stable, did not have any significant apnea or bradycardia events, and experienced self-limiting desaturation events that were felt to be associated with feeding (i.e., pacing issues).

Because the patient was hemodynamically stable, breathing unassisted room air, on full oral feedings, had completed intravenous antibiotics with a blood culture that was negative at 48 hours, and did not have any significant cardio-respiratory events, the patient was medically ready for discharge to home.


The infant was of term gestation, being born at 37.0 weeks estimated gestational age. Any term infant who experiences apnea requires a thorough investigation. No apnea events were documented. Observation of feeding related events for a period of 2-3 days is appropriate for those infants who require more than just pacing. This infant did not require more than pacing for the resolution of the self-limited events.

Events that occur during feeding are generally not reflective of an underlying breathing abnormality and are more reflective of immature suck/swallow coordination. These are not physiologically related to apnea of prematurity. These events, typically, do not justify a traditional apnea countdown but generally warrant actions such as pacing and adjusting nipple flow for those infants who are bottle fed. In this case, the documentation is supportive of primarily self-resolved events associated with feeding and improved with pacing. None of the events had documented apnea or bradycardia and none required vigorous stimulation.

Therefore, the requested continued inpatient stay was not medically necessary for this patient.