Question DENIAL SMALL FOR GESTATIONAL AGE

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Smithfield, ME
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We have received a denial for SMGA in 39 week old infant with uncomplicated vaginal deivery. Apgars 8 at 1 minute and 9 at 10 minutes. The infant was 19.25 inches long weighing 2800 gm. The hospital stay was 5 days. Monitoring the first 24 hours for hypoglycemia was normal. The infant was exposed inutero to Subutex, THC, and tobacco. The reviewer is denying P05.19 saying there was no treatment. Can this be rebutted. M Bushey, M.D.?
 

SharonCollachi

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If appropriate, I would look at: P04.14-Newborn affected by maternal use of opiates.

Your first action should be to obtain the insurance company's policies on maternal care, newborn care, and at-risk newborn care, and if they have a specific policy for exposure to opiates. If they violate their own policies, then that is an easy appeal. If they followed their own policies, that is a bit harder, but it can still be done if it is against recognized standards of care.
 
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