Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 21-month-old male who has been diagnosed with interstitial 6q deletion. The patients caregivers were noted to include his mother, aunt, and grandmother. The provider noted the patient is status post tracheostomy due to a difficult airway and craniofacial anomalies. The patient also has Pierre Robin sequence, absent corpus callosum, cleft palate, and severe dysphagia. The records noted no pneumonias or severe respiratory illness since his last visit. He was noted to be on room air during the day and was on 2.5 liters of oxygen at night.  The records noted that the patient required tracheostomy care and suctioning. He presents with global developmental delays and received physical and occupational therapy. The patient received feedings though his gastrostomy tube. He did not take food orally due to severe dysphagia but did eat a small amount of baby food for therapy once per day. The patients pulse oximetry readings have been in the 90s, and he receives albuterol nebulization twice daily. The patients parent has requested authorization and coverage for an additional 15 hours per week of home health services (72 hours per week total). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether that an additional 15 hours per week of home health services (72 hours per week total) are medically necessary for the treatment of the patients medical condition. Authors reported, Parents providing palliative care for children with lifelimiting diseases spent an average of nine hours a day caring for them each day and had to maintain an average of five medical appliances. Researchers reported, Disease burden appears to be particularly high for children and families with tracheostomies, especially when compared to other serious childhood disease. Lack of time and energy to complete daily activities, social isolation, worries, as well as difficulty communicating and perceived lack of understanding of their childs health were instrumental in reduced quality of life of caregivers. Anxiety about the future affected the majority of caregivers. This patient has chronic conditions and functional limitations that make him dependent on caregivers and the use of complex medical appliances. In this case, the patient is successfully living at home with no need for frequent hospitalizations. With the current care he is receiving, he is remaining medically stable and showing some developmental progress. There is no surgery planned for near future. The medical evidence does not support the requested services in this clinical setting. Therefore, an additional 15 hours per week of home health services (72 hours/ week total) are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.