CLINICAL SUMMARY:
A newborn infant, just over one-month-old, arrived at the Emergency Department (ED) under the direction of a pediatrician, who was concerned about lack of weight gain since birth. The infant was born weighing 8 pounds, 5 ounces and weighed 8 pounds, 5.5 ounces one month and five days after birth. The patient’s weight was in the 80th percentile at birth and dropped to the 10th percentile at the time of admission. The infant’s parents reported feeding the infant 2 to 3 ounces of infant formula every two to three hours, with no emesis or spit-up. The parents also communicated that the patient had regular, green-colored bowel movements and wet diapers. No other concerns were noted, with the parents denying any symptoms of sickness, including coughing, congestion, fever, vomiting, and diarrhea.
Physicians in the ED noted the infant as “well-appearing” upon examination. The patient had normal vital signs for age. Labs were drawn and significant for mild hyponatremia at 133, potassium elevated to 6.2 and grossly hemolyzed, mild elevation of AST 66, ALT 51, CBC with neutropenia (ANC 0.78), Hgb 15.8 and Hct 44.2. The urine tox screen was negative, with the UA showing no signs of infection. The infant was admitted to an inpatient (IP) level of care (LOC) for failure to thrive with close monitoring of intake and output, and lack of weight gain with further evaluation of poor weight gain cause.
During the hospital stay, the patient tolerated 90 ml of formula every three hours, while also gaining weight two days in a row, an average of 100g/day. The infant was discharged with specific feeding instructions and a follow-up with his pediatrician to check the infant’s weight within a week.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe Managed Medicaid plan denied the two-day inpatient stay for acute treatment, citing that the LOC was not medically necessary. The denial stated that the patient’s documentation did not show severe problems with nutrition and weight gain to support acute pediatric failure to thrive guidelines.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSThe hospital referred this case to AppriseMD, and an AppriseMD physician advisor engaged in a peer-to-peer review with the insurance company medical director. The physicians discussed the case, including the factors resulting in the infant being admitted to IP LOC due to failure to thrive. The AppriseMD physician advisor homed in on a key factor in the medical record, which was that the infant was born weighing 8 pounds, 5 ounces and weighed 8 pounds, 5.5 ounces one month and five days after birth. This represented a significant crossing of percentiles within a brief period. Further, the initial ED evaluation showed transient neutropenia (normalized on repeat), mild hyponatremia and minimal transaminitis.
The physician advisor added that inpatient monitoring, nutritional assessment, and stabilization were performed, resulting in the patient being discharged in stable condition. Given the degree of growth faltering with the crossing of two major percentile lines in less than two months, the payer medical director agreed that IP LOC was appropriate and overturned the denial.