Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Nutritional Supplement. 
The health plan denied the requested Enteral Therapy Nepro for a total of 383 units per month. 
The health plan's determination is upheld.

The patient is a male with a history of hypertension (HTN), hyperlipidemia, benign prostatic hyperplasia (BPH), dementia, prostate cancer, and chronic kidney disease (CKD) stage 3 who presented with a near syncopal event. He had several prior hospitalizations over the past few months. He reported vomiting while on way to a physical visit and became weak. The patient denied fevers, diarrhea, or abdominal pain. His exam was unremarkable. His labs showed a sodium of 136, a potassium of 5.3, a carbon dioxide (CO2) of 20, a creatinine of 5.3, a blood urea nitrogen (BUN) of 56, a white blood cell count (WBC) of 6.9, and a hemoglobin of 8.2. A chest x-ray (CXR) showed an enlarged heart size. A head computed tomography (CT) did not show any focal intracranial abnormalities. A post void residual bladder scan was performed and showed 1000cc (cubic centimeter) of urine retained in the bladder. The patient was admitted for further management. Nephrology evaluated the patient and recommended a renal ultrasound and provide Lokelma to treat the hyperkalemia. An electrocardiogram (EKG) showed sinus rhythm with a left anterior fascicular block. Cardiology evaluated the patient for his hypertensive heart disease.  They recommended Labetalol for his blood pressure and holding on the Losartan due to his hyperkalemia. A renal ultrasound showed findings suggestive of renal parenchymal disease and/or dehydration, right sided hydronephrosis, a collapsed bladder around a Foley catheter and an enlarged prostate. His creatinine did improve on further studies to 4.9, as did his potassium to 4.7. He was also placed on antibiotics for a presumed cystitis. His renal function remained stable through his hospital course. The patient was discharged home with a Foley in place. A home assessment was done, which noted that the patient is completely dependent on others for meal preparation. This report also noted that he has not reported weight loss of 5% (percent) or more in the last 30 days, or 10% or more in the last 180 days, no signs of dehydration, no evidence of fluid intake less than 1000cc a day and that he was able to swallow all types of foods. He later presented after pulling his Foley catheter out and was found to have hyponatremia and a presumed urinary tract infection (UTI). He was discharged on a 2-gram sodium diet. The patient later presented with a dislodged Foley catheter. A provider for the patient has prescribed Nepro enteral treatment for a total of 383 units per month.  At issue is the medical necessity of the requested enteral therapy.

The health plan's determination of medical necessity in this case is upheld.

The requested treatment of Enteral Therapy Nepro for a total of 383 units per month is not medically necessary, based on the documentation provided. The patient has a history of dementia, progressive CKD and chronic urinary retention requiring a Foley catheter. He is home bound and requires full assistance for meal preparation. However, there is no documentation that he requires enteral therapy with Nepro of any other enteral supplement. He does not have documented weight loss, inability to swallow solid foods, or other signs of symptoms of malnutrition that would necessitate nutritional supplementation. A home assessment does not indicate any of these findings.