Diagnosis: Childbirth.
Treatment: Full Hospital Admission - Neonatal Intensive Care Unit (NICU).
The insurer denied Full Hospital Admission - Neonatal Intensive Care Unit (NICU).
The health plan's determination is overturned.

The female patient was born by vaginal delivery at 41 weeks' estimated gestational age to a primigravida mother. Mild shoulder dystocia was noted during the delivery. She was noted to have a nuchal cord x1 and was initially floppy but responded to routine newborn resuscitation. Her Apgar scores were 7 and 8 at one and five-minutes of age. Her birth weight was 3.93 kilograms.
The infant was initially admitted to the newborn nursery, but she had a dusky episode and drop in oxygen saturation to the high 80's during which she turned red and the saturation was then in the low 80's. She was noted to possibly be breath holding. The neonatologist was consulted, and the infant was transferred to the Neonatal Intensive Care Unit at approximately 6 hours of life for further stabilization and management.

The requested Inpatient Hospital Admission-Neonatal Intensive Care Unit (NICU) was medically necessary for this patient.

On day 1, the patient was hemodynamically stable; mild grunting/subcostal retractions on admission that resolved without intervention; chest x-ray consistent with retained lung fluid. A head ultrasound was obtained and was read as normal. Magnetic resonance imaging (MRI) of brachial plexus obtained. Oxygen saturation was 99% in room air at admission. Temperature instability was noted and the neonate was in the incubator.
On day 2, the patient was hemodynamically stable, breathing unassisted on room air; ad lib feeding in an open crib; and diagnosed with Erb's palsy.
On day 3, there were no changes. The plan was to monitor for apnea, bradycardia, desaturation events for 3 days. Critical congenital heart disease screen was passed; Hepatitis B vaccine was given. Hearing screen passed.
On day 4, there were no changes; echocardiogram showed patent foramen ovale and no patent ductus arteriosus; medically stable for discharge to home with the parents.
During the dates in question, the infant met inpatient criteria for Admission-Neonatal Intensive Care Unit secondary to the criteria: temperature instability, meconium stained amniotic fluid and polycythemia. A lower level of care was not appropriate.