Failure To Thrive: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting reimbursement for intensive tube weaning program services. The enrollee has diagnoses of hypertrophic cardiomyopathy and Noonan’s syndrome. He was an oral eater until approximately three months of age. He breast-fed for the first four weeks of his life and transitioned to bottle feeding. His family observed loud breathing, frequent vomiting, and poor weight gain during this time. He was hospitalized at one and a half months for 10 days due to recurrent vomiting and failure to thrive. He underwent a supraglottoplasty for his laryngomalacia and tracheomalacia. He was hospitalized one month later for recurrent vomiting, chronic upper respiratory infections, and failure to thrive. A nasogastric (NG) tube was placed due to decreased weight gain, feeding refusal, and failure to thrive.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for in-home private during nursing home services. Kuo and colleagues noted that the parents of medically complex children with special health care needs spend an average of nearly nine hours per day managing the patient’s basic healthcare needs, such as personal hygiene and feeding, administering drugs and managing symptoms, pain and sleep related problems during the night. Current data shows that the number of medical appliances and the status of single caregivers correlated proportionally with a greater amount of time needed for the patient’s care. It is important for patients’ families to receive appropriate support with daily care tailored to the patient’s individual needs.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for continued in-home private duty nursing services for 86 hours per week. Home based nursing services are essential for the parents of young patients with life-limiting or life-threatening diseases who spend an average of nearly nine hours per day managing the patient’s basic healthcare needs such as personal hygiene and feeding, administering drugs and managing symptoms like seizures, pain, and sleep related problems during the night. Current data shows that the number of medical appliances and the status of single caregivers correlated proportionally with a greater amount of time needed for the patient’s care. It is important for these families to receive appropriate support with daily care, through the evaluation of individual needs of the patient and organization of care models.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Genotropin growth hormone (GH) therapy for treatment of the enrollee’s short stature. The physician reviewer found that this patient has failure to thrive and constitutional delay in association with a chronic inflammatory condition. Although his testing revealed a peak GH response of less than 10 ng/mL to provocative testing, such testing has poor specificity for the diagnosis of GH deficiency in a patient with delayed puberty who is also underweight. In addition, a low IGF-1 level in a patient who is underweight is not specific for GH deficiency. There is also a lack of biochemical evidence that this patient has other pituitary deficiencies to raise concern about a broader diagnosis of hypopituitarism.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for failure to thrive was denied, the published record says the denial is worth fighting.