Diagnosis: Brief Resolved Unexplained Event (BRUE).
Treatment: Inpatient hospital stay.

The insurer denied coverage for inpatient hospital stay.
The denial is overturned.

This is the case of a female infant, 36 weeks gestation, with newborn admission for respiratory distress, hemolytic anemia, and hyperbilirubinemia presented to the emergency department (ED) with sudden-onset of choking and difficulty breathing followed by decreased responsiveness, appearing limp with pallor and cyanosis at home. Her father performed cardiopulmonary resuscitation (CPR) while her mother called emergency medical services (EMS) who found the infant to be pink, provided oxygen and documented an adequate oxygen saturation. In the ED, vital signs included a respiratory rate of 39 and a heart rate of 175. She appeared congested, but in no acute distress. A chest x-ray was interpreted as possible mild respiratory distress or viral inflammation in the lungs. She was diagnosed with a Brief Resolved Unexplained Event (BRUE) and admitted to the pediatric intensive care unit for continuous cardiopulmonary monitoring "in the setting of a higher risk BRUE given prematurity and CPR event". She remained stable until discharge.

The insurer denied coverage for an in-patient admission asserting the patient only required ED care.

However, according to MCG (Milliman Care Guidelines): Apparent Life-Threatening Event (Brief Resolved Unexplained Event) (P-12): Admission is indicated for: Diagnosis of apparent life-threatening event (brief resolved unexplained event) appropriate, as indicated by ALL of the following: 1) Infant younger than 1 year of age, 2) Event is reported (eg, by observer) as having included 1 or more of the following: Cyanosis or pallor, Absent, decreased, or irregular breathing, Marked change in tone (eg, hypertonia, hypotonia), 3) Altered level of responsiveness (eg, loss of consciousness, lethargy), 4) Infant recovered fully to baseline state of health after event (eg, normal appearance, vital signs), 5) Event remains unexplained after history and physical examination, 6) 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.

The health care plan did not act reasonably with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital stay is overturned. Medical Necessity is substantiated.