Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 50-year-old female with Crohns disease and a history of multiple abdominal surgeries for subtotal colectomy and an ileostomy. A small bowel motility test in 2001 did not show any evidence of myopathy. The patient has been receiving total parenteral nutrition (TPN) for the past seven years. The Health Plan has determined that continued TPN is not medically necessary. The patient has refused oral nutrition and wishes to continue to receive TPN.In 1981 the patient had surgery for active Crohns disease that left her with a colostomy. In 1991 the patient had a total colectomy resulting in an ileostomy. In the 1990s the patient reportedly had gastrointestinal motility studies that demonstrated abnormalities of transit. The patient reports developing allergies to numerous foods and dietary supplements. The patients diet became progressively restricted until even strained baby food could not be tolerated. At that point in 1997 the patient weighed 78 pounds and her providers recommended total parenteral nutrition (TPN) as the best method to deal with her gastrointestinal and nutritional problems.  In the subsequent seven years the patients TPN has continued, albeit with numerous changes secondary to allergic reactions to components of the formula. The patient reports trying to orally consume various foods and food supplements, including Ensure, none of which can either be tolerated or which create allergic responses. During the past seven years the patient has had at least three infections at the site of her feeding line. The patient expresses informed consent of the risks of TPN and provides self-care along with vancomycin treatment of her line. It appears that the patient is seen approximately once a year for evaluation of her indwelling feeding line (PICC).The patients medical records provided by the Health Plan include a consultation note from 2001, two visits with the feeding line specialist, and four or five outpatient visits. Two visits were related to a chief complaint of an upper respiratory tract infection and two for oral thrush. The only laboratory values are from April 2004  with the significant values being anemia with low-normal ferritin and a low iron saturation. There are no records discussing attempts at oral feeding, new evaluation of the patients gastrointestinal status, or investigation into the 2001 note that the patient was refusing to attempt oral intake and/or gastrointestinal tract function testing.  The patient has a long-standing TPN usage. She originally started TPN because of severe marasmus. The patients gastrointestinal function evaluations were last performed in the distant past and are not currently available. The patient has self-reported, and not contradicted, multiple allergies to nutritional supplements. There is no documentation within the past three years of attempts to increase oral intake. There is no documentation within the past three years that there was an interest in evaluating the status of the patients gastrointestinal tract. There is no plan in place to transition the patient from TPN. Furthermore, if the patient were to be converted from TPN to enteral feeding, it would be a slow process for her physiology to return to normal rhythm. Moreover, no documentation has been submitted demonstrating that discontinuation of TPN is medically indicated for this patient.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.