Special Foods denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Ensure formula.Poor nutrition is common in individuals with cerebral palsy and has a wide-ranging impact on their health and well-being (Rempel, G.). Ruiz Brunner and colleagues conducted a cross-sectional study to describe the nutritional status of children with cerebral palsy (CP) and to analyze their risk of undernutrition based on their Gross Motor Function Classification System (GMFCS) level. They found that there is a high prevalence of undernutrition associated with CP (GMFCS levels IV and V) and that risk of severe undernutrition increases with increased motor compromises. Bell and Samson-Fang note that children with severe cerebral palsy, and particularly those with oropharyngeal dysfunction, are at high risk of poor nutritional status.

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for Nutramigen infant formula. The Health Plan has denied this request indicating that the requested formula is not medically necessary for treatment of the enrollee who has a history of severe constipation.Findings: The medical studies show that adverse reaction to cow’s milk protein is common in infants. The prevalence of cow’s milk protein allergy (CMPA) ranges from 2% to 7.5%. Immediate symptoms may include vomiting, urticarial, angioedema, wheezing, rhinitis, and dry cough. Later symptoms may include moderate to severe atopic dermatitis, diarrhea, and blood in the stool, gastroesophageal reflux and constipation.

Where the denial was upheld

Findings: The physician reviewer found that the patient has requested authorization and coverage for medically tailored meals. The Food is Medicine Coalition describes medically tailored meals as medically appropriate meals delivered to the homes of individuals living with complex, severe, or chronic illnesses who are too sick to shop or cook for themselves. These meals are supervised by registered dieticians and tailored toward the specific nutritional needs of eligible recipients. Nutrition and diabetes are intricately intertwined. Authors report that the foundation of medical nutrition therapy for type 2 diabetes is to achieve glucose, lipids, and blood pressure within the target range to prevent, delay, or manage microvascular and macrovascular complications.

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent has requested coverage for Nutramigen baby formula. A review of the records indicates the enrollee is growing well and gaining weight. Formula is noted to be Nutramigen 4 ounces very two to three hours. There is no documentation of allergies or rashes. Growth and development is appropriate. A referral request was for EF Ped Hydrolyzed/Amino Acid for symptoms of clay like stool, formula concern. Physician indicates tried Nutramigen and doing well, will refer for formula. A prescription by the provider was for Nutramigen. Per addendum, the mother indicated the enrollee gets a rash with Gentlease and Reguline. According to the medical literature, the majority of children with cow milk protein allergy have one or more symptoms involving one or more organ systems, mainly the gastrointestinal tract and/or skin.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Special Foodswhen you appeal: reviewers routinely find that denials like yours didn’t hold up.