Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal Reflux

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a female child with a past medical history notable for hypotonia, macrocephaly, plagiocephaly and torticollis. The patient was feeding well until solids were introduced to the patient's diet. The patient poorly tolerated this advanced diet. 

Based on the review of the medical record, the issues leading up to this patient's admission were vomiting, and tolerating only 4-6 ounces per day. The patient was referred to gastroenterology for evaluation. 

The patient was admitted for further evaluation, possible tube feeding and monitoring for refeeding syndrome. The patient had no associated upper respiratory infection (URI) symptoms, sick contacts, travel, distention, dehydration or weight loss. The patient's physical exam showed a well-developed, well-nourished female in no apparent distress.

Based on the review of the medical record, this patient appears to have food refusal in the setting of the introduction of solids and untreated gastroesophageal reflux.  The patient's history of altered intake over 10 days prior to admission was inconsistent with her presenting weight, hydration status, physical exam findings and laboratories.  The sense of urgency to admit this patient for a multidisciplinary evaluation in the setting of a large head without hydrocephalus, hypotonia without significant delays and a feeding disorder despite above average height and weight is not justified for inpatient admission. The notion that this patient required admission for close monitoring of refeeding syndrome is also not valid.  

According to the ASPEN consensus recommendations for refeeding syndrome, the literature identifies the following elements contributing to the risk of refeeding syndrome in pediatric patients: (1) Low weight for length Z-scores; (2) Weight loss; (3) Energy intake; (4) Abnormal pre-feeding electrolytes (potassium, phosphorus, magnesium); (5) High risk comorbid conditions (immunodeficiency states, eating disorders, significant dysphagia, food insecurity, FTT, malabsorptive states, cancer, advanced neurologic impairment, prolonged fasting); (6) Loss of subcutaneous fat; (7) Loss of muscle mass. However, in this case, this patient was at minimal or no risk of refeeding syndrome that would have warranted inpatient admission and level of care. 

In regards to this child's likely cause of her presenting symptoms in a review of gastroesophageal reflux in children from UpToDate the authors state that "Feeding refusal is occasionally, but not commonly, caused by GERD.  A variety of other disorders, including eosinophilic esophagitis (also rare in infants), can cause feeding refusal, and diagnostic testing should depend on associated symptoms.  If a strong suspicion of gastroesophageal reflux disease (GERD) remains, the evaluation and treatment are similar to that of an infant with reflux and poor weight gain and an empiric trial of a milk-free diet or a limited trial of drug therapy can be considered.

In this case, this patient had macrocephaly with an unremarkable outpatient head ultrasound, and hypotonia without significant delays or prior feeding problems.  These two conditions alone do not constitute a high-risk situation in need of urgent inpatient assessment.

This patient needed treatment to address her gastroesophageal reflux that could have been safely instituted in the outpatient setting as per customary practice.  Evaluation by a feeding therapist with education and assurance to this patient's family would have avoided an unnecessary inpatient admission. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for inpatient admission should be upheld.  The medical necessity is not substantiated.