Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory distress.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

At the time of presentation, the patient was a newborn female. She was born via spontaneous vaginal delivery. She was 37 6/7 weeks. She had birthweight of 2285 grams. She had Apgar scores of 4 and 7 at 1 and 5 minutes.
The infant was born to an adult female. The mother was with gestational hypertension and pre-eclampsia. The patient was non-vigorous. She required PPV (positive pressure ventilation) at 50% (percent). She was initially admitted to the NICU (neonatal intensive care unit) and then transitioned to newborn nursery. Her heart rate was below 100 and oxygen saturation below 80, gasping respirations, decreased tone and flaccid. She was vigorously stimulated, suctioned, dried, and placed on PPV (positive pressure ventilation) and continuous pulse oximetry. The patient was noted to be grimacing. By 2 to 3 minutes, oxygen saturations improved, and FiO2 (fractional inspired oxygen concentration) decreased to 21%, and respiratory support was discontinued. The infant heart rate was 140, O2 sat (oxygen saturation) 96-97%. The infant was allowed to stay with the mother. The infant re-evaluated at 15 minutes. Oxygen saturation was 100% and HR (heart rate) was 150. Notes state the patient remained with her mother. The infant was noted to be small for gestational age. The infant subsequently required normal newborn care and was discharged home on Day #3. The health plan denied coverage of the inpatient admission. Their rationale was cited as, "We have re-reviewed the specific circumstances and health condition as documented in the appeal and clinical information you provided to us. The reviewer is a health plan Medical Director, an MD who is board certified and specializes in Pediatrics. It's their recommendation that we keep or previous coverage decision. Here's why:
The request tells us your patient was in the hospital intensive care unit (pediatric intensive care unit or neonatal intensive care unit, NICU). The plan clinical criteria consider admission to the NICU [neonatal intensive care unit] medically necessary when severe problems exist. These might include feeding problems, fever, or low level of oxygen in your blood. The information we have does not show your patient had these or other severe problems. For this reason, the request for NICU [neonatal intensive care unit] care is denied as not medically necessary, but your patient's care at the General Nursery level may be approved. It may help to know we reviewed this request using the MCG [Milliman Care guidelines] guideline, as modified by your patient's plan, called Newborn Care, Term, with Severe Illness or Abnormality." The denial is being appealed.

The Inpatient Hospital Admission (Pediatric Intensive Care Unit or Neonatal Intensive Care Unit) was not medically necessary.

Per the provided records, the care provided was normal for newborn. The patient did require resuscitation at birth, however, following appropriate resuscitation, the infant stayed with the mother and received routine newborn care. The patient was noted to be small for gestational age but did not require intervention at NICU (neonatal intensive care unit) level of care such as oxygen, CPAP (continuous positive airway pressure), gavage feeds, external warming with incubator or radiant warmer, IVF (intravenous fluids) or any other interventions. Therefore, the admission to the neonatal intensive care unit was not medically necessary.