Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Brief Resolved Unexplained Event

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
Infant, born at 40 weeks gestation, presented via emergency medical services (EMS) after being unresponsive at home for approximately 4 minutes. His mother stated the patient woke up out of sleep screaming crying and stated "It looks like he was in pain, and I got nervous because he let out such a cry that it looked like he wasn't going to stop". The patient had been constipated x 2 days, eating normally (both breast and bottle fed). For four minutes, the patient's eyes were closed tightly, mouth was shut closed, and both hands were in fists. Patient's eyes rolled back, and he returned to baseline. There were no interventions by EMS. The patient's mother denied bluish skin color or shaking of head or extremities. There was no history of a prior event. In the emergency department (ED), the patient's physical assessment was normal. Labs were only significant for a lactate of 2.8 that decreased the next day to 1.61. 

According to provider documentation, the patient met high-risk criteria for a Brief Resolved Unexplained Event (BRUE) and in accord with guidelines was admitted. During the hospital stay, all diagnostic tests, including an electroencephalogram (EEG), were normal. There was no subsequent event while the patient was continuously monitored.

This infant suffered what is now classified as a Brief Resolved Unexplained Event or BRUE. Previously, this was referred to as an Apparent Life-Threatening Event (ALTE). According to InterQual, Pediatric, Medical, an Acute level of care (In-patient) was met on Episode Day 1 for BRUE and altered level of responsiveness in a high-risk patient (<60 days old) with diagnostic evaluation and monitoring including both continuous cardiac monitoring and continuous pulse oximetry.  

Also, according to Milliman Care Guidelines (MCG) P-12, Admission is indicated for ALL of the following:   

Diagnosis of apparent life-threatening event (brief resolved unexplained event) appropriate, as indicated by ALL of the following:

	Infant younger than 1 year of age
	Event is reported (e.g., by observer) as having included 1 or more of the following:
	Cyanosis or pallor
	Absent, decreased, or irregular breathing
	Marked change in tone (.e.g., hypertonia, hypotonia)
	Altered level of responsiveness (e.g., loss of consciousness, lethargy)
	Infant recovered fully to baseline state of health after event (e.g., normal appearance, vital signs)
	Event remains unexplained after history and physical examination. 
	Infant at increased risk for recurrence, serious underlying disorder, or unsafe discharge, as indicated by 1 or more of the following:
	
	Infant age younger than 60 days
	Infant born at less than 32 weeks' gestation and now at less than 45 weeks' postconceptional age
	Cardiopulmonary resuscitation (CPR) administered by medical personnel during or after event
	Duration of event is 1 minute or longer.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.