Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Newborn respiratory distress

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

 
This infant  was born via vacuum assisted vaginal delivery. Apgars were 8 and 9 at one and five minutes, respectively. Delivery room resuscitation included warming, drying, stimulating, suctioning and continuous positive airway pressure (CPAP) via Neopuff of 5 centimeters (cm) and fraction inspired oxygen (FiO2) 0.21. There were crackles on lung auscultation, grunting, subcostal retractions, and nasal flaring. The infant was admitted to the NICU (Neonatal Intensive Care Unit) for respiratory distress. Upon admission, the physical examination was significant for acute distress, cranial molding with right facial/temporal swelling, tiny subconjunctival hemorrhage over medial portion of left sclera, respiratory distress, nasal flaring and retractions present. Treatment included nasal bubble CPAP.  Of note, rupture of membranes (ROM) was 21 hours and 26 minutes. Due to concern for possible sepsis, the infant was treated with ampicillin and gentamicin until cultures had no growth. Initially she was nothing by mouth (NPO) and provided intravenous (IV) fluid.   

According to the American Academy of Pediatrics (AAP), Clinical Practice Guideline revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation (Pediatrics Volume 150, Number 3, September 2022), risk factors for developing significant hyperbilirubinemia included: lower gestational age, jaundice in the first 24 hours (bilirubin at 25 12 hours old was 10.3 mg/dL), phototherapy before discharge, scalp hematoma or significant bruising.  For this infant, at 96 hours-old, the phototherapy threshold was 20. However, the AAP noted "it is an option to begin phototherapy at subthreshold level during a birth hospitalization to reduce the risk of readmission if the absolute level or rate of rise in relation to the slope of the phototherapy threshold suggests there is a high likelihood of exceeding the threshold after discharge". 

With respect to duration of treatment, according to the AAP, "discontinuing phototherapy is an option when the total bilirubin has decreased by at least 2 below the hour-specific threshold at the initiation of phototherapy. A longer period of phototherapy is an option if there are risk factors for rebound hyperbilirubinemia (e.g., gestational age < 38 weeks). 

In view of this infant's course with risk factors of gestational age and scalp hematoma as well as an increase in total bilirubin level of 4.5 in the past 24 hours, the decision to start phototherapy and continue hospitalization was in accord with the standard of care. However, although measurement of a "rebound" bilirubin level on the day after discontinuing phototherapy was in accord with the AAP Guideline, it was not medically necessary for the infant to remain hospitalized because the level could have been determined as an out-patient.  
In view of the above, the admission is for all days but the final hospital day.

Based on the above, the insurer's denial must be modified. 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 full hospital admission is substantiated. Uphold denial of the final hospital day.