Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Failure to Gain Weight
	
Treatment: Inpatient Hospital Services

The insurer denied the inpatient hospital services. The denial was upheld.   

This is a male infant patient who presented to the Emergency Department (ED) by the mother after being evaluated by his pediatrician for his poor weight gain. It was reported that the mother was breast feeding the infant with formula supplementation; Similac.  On physical examination it was noted that the infant was alert and active in no apparent distress. The patient's mucus membranes were moist with normal skin turgor, and his capillary refill was < 2 seconds, and his abdominal exam was reportedly soft with mild tenderness to palpation in the lower abdomen without associated guarding, organomegaly, distension, rebound, or masses. An electrocardiogram (EKG) was performed and normal for age. The patient was given formula in the ED that was well tolerated. He was admitted to the hospital for further evaluation and treatment. Increased volume of formula was given with tolerance and a positive weight gain. The mother received feeding advice and feeding goals were implemented. The patient was discharged home with the mother with outpatient follow up instruction.  
Based on the review of the medical record, this patient appeared to have a slow weight gain in the setting of inadequate intake.  The reason for the poor intake was secondary to the mother's low breast milk production, limiting feeds to 2-3 ounces to avoid vomiting and failure to feed for extended hours when the patient was sleeping.  The patient's physical exam, laboratories and vitals were for the most part unremarkable.  Accordance to a review of the etiology and evaluation of poor weight gain in children less than 2 years of age from UpToDate the authors state the following: 
Poor weight gain is common.  It occurs in approximately 5 to 10 percent of children in primary care settings and 3 to 5 percent of those in the referral setting.  Medical risk factors for poor weight gain include prematurity (particularly when associated with intrauterine growth restriction), developmental delay, congenital anomalies (eg, cleft lip and/or palate, genetic or chromosomal disorders), intrauterine exposures (eg, alcohol, anticonvulsants, infection), lead poisoning, anemia, and any medical condition that results in inadequate intake, increased metabolic rate, maldigestion, or malabsorption.  Virtually every organic disease process may contribute to poor weight gain.
Psychosocial risk factors for poor weight gain include poverty, certain health and nutrition beliefs (eg, fear of obesity or cardiovascular disease, prolonged exclusive breastfeeding), social isolation, life stresses, poor parenting skills, disordered feeding techniques, substance abuse or other psychopathology, violence, and abuse
The majority of cases in primary care practice are secondary to inadequate dietary intake, usually related to psychosocial factors or disturbance in feeding behavior dietary intake is also a common cause of poor weight gain among infants referred to specialty clinics.
Observation of the child being fed when he or she is hungry may disclose a variety of factors contributing to insufficient intake.  Observation also may provide opportunities to provide positive reinforcement to the caregivers (eg, by pointing out how the child looks to the caregiver for comfort and support or how the caregiver appropriately responds to the child's cues).  Such observation may occur in the office, hospital, or by an experienced visiting nurse in the child's home environment.
The health plan acted reasonably with sound medical judgment and in the best interest of the patient.
The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.