Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thrombocytopenia with absent radius (TAR) syndrome.

Treatment: inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission. 

The denial is modified. 

This patient is a newborn female born via cesarean section due to a fetal diagnosis of TAR syndrome.  Following birth her examination was consistent with TAR syndrome. She was noted to have bilateral shortened arms with normal upper arms and syndactyly of her left hand. Initially, she was in well newborn, rooming in with her mother, in an open crib, and tolerating feedings with normal voiding and stooling. Pertinent labs were blood type O+ with Coombs Negative.  Hgb/Hct 14.5/44.6%.  The bilirubin was 10.3 (at a specified number of hours old).  A Hematology consultation noting no bleeding with platelet counts ranging from 90,000 to 147,000, mild anemia, and elevated reticulocyte count, no ABO or Rh incompatibility with DAT negative, and no evidence of hemolysis on a smear although mild hemolysis could not be ruled out.   The Hematologist recommended daily platelet counts while hospitalized with >50,000 as adequate for discharge.  There was no bilirubin determination on a specified date. The bilirubin was 5.8 and phototherapy was discontinued. The bilirubin showed a mild rebound to 6.3.  The platelet count was 130,000. From a specified date forward, the infant was well, in an open crib, with adequate feeding, voiding and stooling.  It appears that she was kept hospitalized for daily diagnostic tests, i.e., CBC and reticulocyte counts. 

IVIG was administered purportedly for a high reticulocyte count. Although, this might have been indicative of hemolysis, there was no blood group incompatibility, i.e., negative Coombs. A Hematology consult was not done until after initiation of phototherapy and treatment with IVIG.  It was unable to confirm the presence of hemolysis and appeared mainly to be done for the TAR syndrome.    When the bilirubin had decreased to 8.6 on date the infant could have been discharged with a follow-up bilirubin the next day as an out-patient.
According to MCG:   Neonatal Intensity of Care Criteria >Intensity of Care Criteria 2 - Continuing Care (LOC-011):  Continuing Care: Intensity of Care Criteria 2 is for a neonate who is not severely ill but needs more hours of nursing and medical care than normal neonates as indicated by ALL of the following:
"Physiologic stability as indicated by ALL of the following:
Hemodynamic stability, neonatal
No respiratory distress (eg, no respiratory rate greater than 60 breaths per minute, no evidence of difficulty breathing (eg, grunting, chest retractions, nasal flaring), no supplemental oxygen requirement)
Apnea requiring treatment (medication, stimulation) absent
Toxic appearance absent
Open crib
Fever absent
Need for temperature support absent  
Care needed for mild instability or condition as indicated by 1 or more of the following:
Neonatal jaundice requiring monitoring or treatment with phototherapy"

In view of the above, the infant's care did meet MCG: Continuing Care Level 2 on specified dates.  For specified dates care was at a normal newborn level, i.e., Level 1. For other specified dates, there was no medical necessity for continuing hospitalization.

Based on the above, the medical necessity for the inpatient hospital admission from a specified date range is substantiated in part as noted above.  The insurer's denial is modified. 

Approve inpatient hospital admission on specified dates at Continuing Care Level 2. Modify inpatient hospital admission two specified dates, approving Level 1. Deny inpatient hospital admission on other specified dates.