Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Nutritional Supplement. 
The insurer has denied Pediasure Grow and Gain Vanilla Liquid. 
The denial is overturned in whole.

The patient is a male. Records reviewed included completed appeal forms. Office visit notes were also reviewed.

The patient has a history of infantile spasms and epilepsy. He has been diagnosed with Neurofibromatosis Type 1. He has severe developmental delay and gastroesophageal reflex. He has had two episodes of pneumonia and is at risk of aspiration. He is non-verbal and uses a wheelchair. He has been taking Pediasure as his main form of nutrition for the past 5-6 years. Prior to starting Pediasure, he had failure to thrive. His growth charts show that his body mass index (BMI) was 14, significantly below the 3rd centile. He is able to take a few bites of soft food, but coughs and chokes. Pediasure was previously covered by Women, Infants, and Children (WIC), but he aged out of the system. He was reported to have lost weight since he has not been receiving Pediasure. He has been consuming Pediasure Grow and Gain Vanilla Liquid 240 ml 6 times daily.
The patient lives with his parents and two siblings. His medications comprise MiraLAX, Valproic acid, Keppra and Phenobarbital. His examination is significant for multiple cafe au lait spots, and developmental delay.
At issue in this review is whether Pediasure Grow and Gain Vanilla Liquid is medically necessary for the patient.

The health plan's determination is overturned.

Pediasure Grow and Gain Vanilla Liquid is medically necessary for the patient. The patient has significant feeding issues and is unable to consume sufficient calories to maintain his weight using regular food. He has been reported to have lost weight since he has not been receiving Pediasure (amount of weight loss was not apparent from the documentation). Prior to starting Pediasure the patient had severe failure to thrive, with a BMI of 14, significantly below the 3rd centile. Prior to denial of Pediasure, his BMI was in the 25th centile.

Malone et al. [1] analyzed the nutritional status of 500 children followed in an early intervention clinic for developmental delay. They found that nutritional risk was identified in 48.6 % of the children. Weight categories were growth faltering (13.5 %), underweight (7.7 %), overweight (8.4 %) and obesity (4.3 %) at initial assessment. The authors concluded that developmental delay predisposes to nutritional deficits.
Henrikson Estrem [2] et al. described that up to 80% of children with developmental delays have feeding problems.

Aftab et al. [3] describe that postnatal growth failure is a persistent feature common to patients with developmental genetic syndromes that are caused by germline mutations in genes encoding proteins of the Ras-Mitogen-Activated Protein kinase (RAS-MAPK) pathway, or Rasopathies, a category of disorders encompassing Neurofibromatosis type 1. "The mechanism of growth failure in Rasopathies is highly complex and there are many proposed hypotheses including partial growth hormone insensitivity, growth hormone deficiency, neurosecretory dysfunction of growth hormone secretion, delayed puberty, poor feeding and skeletal abnormalities."