Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchopulmonary dysplasia, mild reactive airway disease, mild pulmonary hypertension

Treatment: Inpatient stay 

The insurer is denied coverage for inpatient stay.

The denial is modified. 

The patient was a  female child with a past medical history notable for prematurity (over 20 weeks gestation), extreme low birth weight (965 grams), bronchopulmonary dysplasia, mild reactive airway disease, mild pulmonary hypertension (off medications), gastroesophageal reflux, bilateral middle ear effusions with hearing loss, mild developmental delay and feeding difficulties status post gastrostomy tube placement.  After this patient's birth admission, her initial discharge for acute rehab was to for intermediated care.  After a planned stay, the patient was transferred for transitional sub-acute skilled nursing facility care and continued rehab with approval for several months.  The patient was followed by a multidisciplinary team including general pediatrics, ophthalmology, ENT, cardiology and gastroenterology. The patient was cleared medically for discharge but remained a resident until her discharge.  

Based on the review of the medical record, this patient suffered from a number of chronic medical conditions as a direct consequence of prematurity and low birth weight including feedings difficulties and chronic lung disease.  Due to this patient's complex history, safe transition to the home setting required proper care coordination.  

According to a review of the child and youth with special health care needs (CYSHCN) from UpToDate regarding care coordination, care coordination is defined by involving the patient and/or family as partners to address the interrelated medical, social, developmental, behavioral, educational, and financial needs of CYSHCN and enhance the family's caregiving capability to achieve optimal health and wellness outcomes for all.  Care coordination encompasses case management (ie, management of a specific disease or process), care planning (ie, a written, detailed step-by-step strategy to achieve the goals of care), and care mapping (ie, a visual portrayal of patient and family needs and strengths, including interactive relationships among team members and resources).

Based on the review of aspiration in infants and children from UpToDate, this patient was considered at minimal risk for aspiration without history of recurrent pneumonia, impaired oxygenation or frequent deep suctioning. In fact, this patient was not strictly limited to gastrostomy tube feeding. The patient tolerated various pureed foods without event. There as clear documentation that this patient's respiratory condition was stable and uneventful without skilled medical interventions.  Although this patient's history was complex, the challenges for her care plan had certainly reduced over time as the patient grew, developed and rehabilitated (i.e. no tracheostomy, cardiac medications, continuous feeds or oxygen administration).  The limited complexity to this patient's current care plan was such that it was reasonable to expect her trained family to provide this patient the direct health care needs with oversight by a well-coordinated home patient-centered care team. 

Given the above factors this patient's medical condition and care needs did not meet standards for medically necessity for continued inpatient rehab stay beyond.  The patient's medications, follow-up appointments, family education, tube feed needs and visit nurse service follow-up could have been arranged in advance rather than having this patient wait unnecessarily for  additional days.  

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the continued inpatient stay from should be modified Approve 2 days.  Deny 4 days.