Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperbilirubinemia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is modified

This was an infant male. He was breast fed. There was no maternal-infant blood group incompatibility. Lab work revealed a Hematocrit of 58% (percent). Prior to an anticipated discharge, there was a bilirubin level of 12.9/0. An order was entered for triple phototherapy. Nursing documented the infant on phototherapy. According to an MD (doctor's) progress note the plan was to discontinue phototherapy and repeat a bilirubin. According to nursing documentation, "phototherapy was stopped as per doctor". Although there was no order placed, phototherapy was apparently resumed. The bilirubin level was 12.8. Nursing documented triple phototherapy being maintained. An order was placed to discontinue phototherapy. The bilirubin level was 10.7 and later, the bilirubin level was 11.1. Thereafter, the infant was discharged.

According to the American Academy of Pediatrics guideline published in 2004, the threshold for phototherapy was a total serum bilirubin of 14.4. The guideline did allow for "an option to provide phototherapy in hospital or at home at total serum bilirubin (TSB) levels 2-3 points below the threshold". 

According to the American Academy of Pediatrics revised guideline (8/5/2022) published in Pediatrics September 2022, the phototherapy threshold is 16.3. Thus, the infant's total serum bilirubin was 3.4 below the threshold at that time. However, the guideline does state: "These thresholds, like those in the 2004 guidelines, are based on expert opinion rather than strong evidence that they distinguish between infants in whom the benefits of phototherapy do or do not exceed its risks. Clinicians and families may choose to treat at lower levels, based on individual circumstances and preferences. For example, 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 that there is a high likelihood of exceeding the threshold after discharge.  Those making the decision to begin phototherapy below the treatment threshold should consider the risk of overtreatment on the infant and family".

In view of the above, taking into consideration both the 2004 guideline which was in effect in July 2022 and the revised guideline, initiation of phototherapy for a total bilirubin level of 12.9 was in accord with the standard of care. Resumption of phototherapy was in part undertaken because phototherapy had been discontinued earlier and followed by a post-phototherapy rebound. It is more likely than not, had phototherapy been continued the bilirubin level would have sufficiently decreased to allow for discontinuation of phototherapy at that time and discharge one day sooner. Accordingly, the extension of this patient's length of stay, for treatment of hyperbilirubinemia, should have been for only one day. 

In view of the above, the denial is partially overturned with approval for hospitalization for one additional day. However, continued hospitalization for one day is denied.    

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 the continued full hospital admission is modified to substantiate one additional hospital inpatient day.