Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trouble Breathing. 
Treatment: Inpatient Admission. 

The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is a female infant born at term. She was taken to the 
emergency department after experiencing a three-minute episode of becoming limp, possibly not breathing (cousin reported not breathing, mom saw her breathing), turning red without cyanosis. She returned to baseline after three minutes. She did not receive CPR (cardiopulmonary resuscitation). She had not been sleeping well due to teething but had no fevers and was eating at baseline. The patient's vital signs included temperature 37.1 Celsius, heart rate 154, respiratory rate 30, and 
100% oxygen saturation in room air. Examination was significant for no acute distress, congestion without rhinorrhea, moist mucous membranes, regular heart rate and rhythm without murmur, clear lungs, benign abdomen, and non-focal neurologic exam. Labs were unremarkable, with negative viral screen. Electrocardiogram was unremarkable with normal sinus rhythm. Chest X-ray revealed mild perihilar prominence of lung markings consistent with respiratory viral illness. She was observed in the emergency department without distress, no spells, able to feed without difficulty. She was subsequently admitted to the pediatric intensive care unit (PICU) for continued monitoring and observation. She did well with no further spells, activity at baseline, feeding well. She remained stable in room air and was deemed stable for discharge home the next day. 

The Inpatient admission was not medically necessary. 

BRUE, or brief resolved unexplained event, has replaced the term ALTE, or acute life-threatening event. It is defined as a brief self-resolved event occurring in an infant less than a year of age, associated with one or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone; and/or altered level of responsiveness. BRUE (brief resolved unexplained event) is a diagnosis of exclusion. Infants who present for evaluation can be categorized as either high risk or low risk based on careful and detailed history and physical exam. Any abnormalities on exam may place the infant into a higher risk category, with consideration for child abuse if there are inconsistencies in the story or exam, cardiac arrhythmia in the presence of positive family history, and infection if there is fever. To be considered lower risk, the infant must be older than 60 days, gestational age greater than or equal to 32 weeks and postconceptional age greater than or equal to 45 weeks, this must be the first event, the event must have lasted less than a minute, not requiring CPR (cardiopulmonary resuscitation), with no concerning historical or exam findings. While hospitalization overnight or longer for monitoring and evaluation may not be indicated for lower risk infants, hospitalization and further testing may be indicated for high-risk infants. Concerning signs that would warrant hospitalization include toxic appearance, lethargy, or respiratory distress at the time of the event; bruising or other evidence of trauma; history of multiple events in the past 24 hours; history of clinically significant events or unexpected death of a sibling; history that raises suspicion for the possibility of child maltreatment; and dysmorphic features or known syndrome.
This female infant was taken to the emergency department after an observed brief resolved unexplained event (BRUE). She met criteria for low-risk presentation except for the duration of the episode. She had no cyanosis, did not require CPR (cardiopulmonary resuscitation), and had no lethargy or signs of trauma. While it was not unreasonable to monitor her in the hospital, she was overall hemodynamically stable with no oxygen requirement, tolerating feedings, with no further episodes of decreased tone and no color change. Acute inpatient admission was not medically necessary.