Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low weight.
Treatment: Laboratory Service Received from Greenwich Hospital (Vitamin D Testing).
The insurer denied Laboratory Service Received from Greenwich Hospital (Vitamin D Testing).
The determination is upheld.

This is a male child that who presented for well childcare appointment. At that time, his weight was 7.31 kilograms (kg) (2nd percentile) and his length was 71.12 centimeters (cm) (21st percentile), with a head circumference of 46 centimeters (cm) (71st percentile). His examination was unremarkable. He was eating baby foods, table foods, no juice. Low weight was considered to be familial but labs were planned to rule out pathology. Labs included a complete blood count (CBC), comprehensive metabolic panel (CMP), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and celiac disease panel. The vitamin D3 level was ordered and is under review for medical necessity.

No, the laboratory testing for vitamin D3 level was not medically necessary for this patient.
The American Academy of Pediatrics has published guidelines on vitamin D supplementation and testing to optimize bone health in children and adolescents. Current studies of vitamin D status have demonstrated deficiency in 17-47 percent (%) of adolescents. In 2014, new guidelines were available, including updated allowances for calcium and vitamin D, along with recommendations for supplementation and weight-bearing activities. "The American Academy of Pediatrics endorses the higher recommended dietary allowances for vitamin D advised by the Institute of Medicine and supports testing for vitamin D deficiency in children and adolescents with conditions associated with increased bone fragility. Universal screening for vitamin D deficiency is not routinely recommended in healthy children or in children with dark skin or obesity because there is insufficient evidence of the cost-benefit of such a practice in reducing fracture risk." (1) Newborns and infants that are exclusively breastfed may be at greater risk of vitamin D deficiency because of their mother's low vitamin D status. Deficiency is also common among children with severe acute malnutrition. In this case, vitamin D deficiency is associated with severe wasting. High-dose vitamin D3 has been shown to improve mean weight-for-height and developmental index in children receiving standard therapy for acute uncomplicated severe malnutrition.
Children and adolescents at risk for vitamin D deficiency (25-OH-D [hydroxy vitamin D] concentration less than 20 nanograms per milliliter (ng / mL) would include those with obesity, black and/or Hispanic heritage, malabsorption syndromes, and those receiving glucocorticoid, anticonvulsant, antifungal, and antiretroviral medications. Exclusive and prolonged breastfeeding may also be associated with deficiency and nutritional rickets. In addition to identification of risk factors and physical exam findings (eg nutritional rickets), general recommendations for the prevention of nutritional rickets and osteomalacia include supplementing based on age.
There is no indication from the clinical information provided that this infant was at risk for vitamin D deficiency or showed evidence of nutritional rickets. Testing was not medically necessary or consistent with current recommendations.