Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Failure to Thrive

Treatment inpatient emergency admission

The insurer denied coverage for inpatient emergency admission

The denial is upheld

The patient is a teen male with asthma, migraine headaches, scoliosis, constipation, ADHD (attention deficit hyperactivity disorder), and failure to thrive who presented to emergency department (ED) with anorexia, and 4-pound weight loss over 2-week period. The patient is undernourished at baseline. He was admitted for weight monitoring, strict I&Os (intake and output), and was evaluated by nutrition and psychiatry teams. Baseline labs performed and notable for slightly low total protein and phosphorous. The patient was given regular diet and was able to meet goal calories with documented weight gain. He was later discharged. 

Failure to thrive (FTT), more recently known as undernutrition or poor growth, is a condition commonly seen by primary care physicians including pediatricians. While definition of FTT have varied over time, most diagnose FTT when a child's weight for age falls below the 5th % (percent) on the standard growth chart. Hospitalization is rarely required as most children with FTT are managed as outpatients. The lack of benefit to hospitalization in most cases has been apparent for decades. (1) For children who do not respond to initial management, it may be necessary to seek assistance from subspecialists using multidisciplinary approach including dieticians, social workers and psychologists in order to improve outcomes (2).

Fryer published a meta-analysis that compiled the evidence from eight trials that studied the efficacy of inpatient admission for FTT. This study concluded that hospitalization favorably influenced the growth of children with FTT, stating that hospitalization approximately doubled their probability of catch-up growth. In contrast, psychosocial development only moderately improved with inpatient admission. The author was careful to note, however, that none of the studies in the meta-analysis evaluated long-term growth and developmental outcomes in children admitted for FTT. Therefore, while inpatient admission may result in short-term improvements in growth, the long-term efficacy of inpatient admission for FTT is unknown (3).

This patient has baseline undernutrition and concern for further weight loss over 2-week period-unclear if related to dysgeusia from recent Novel 2019 Coronavirus or disordered eating, vs. behavioral. And although patients with low calorie intake over time are at increased risk of refeeding syndrome once calorie implementation is enforced, this patient did not undergo appropriate inpatient monitoring for refeeding syndrome---metabolic panel was only obtained in ED prior to admission. The patient also did not show any evidence of dehydration. The patient does not meet the criteria for admission. 

This adolescent male with chronic undernutrition was admitted with anorexia and 4 pounds weight loss without any other signs or symptoms. During the hospitalization, he was given a regular diet and was able to meet set goal calories with subsequent weight gain without any further interventions. 

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

The insurer's denial of coverage for the inpatient emergency admission is upheld. Medical necessity is not substantiated.