Appeal type: Medical necessity
Decision: Overturned

Diagnosis: amyotrophic lateral sclerosis (ALS).

Treatment: 24 hours per day, 7 days per week of licensed skilled nursing services.

The insurer denied coverage for 24 hours per day, 7 days per week of licensed skilled nursing services.

The denial is overturned.

 
According to the medical records, the patient is an adult male with a history of amyotrophic lateral sclerosis (ALS), hypertension, respiratory failure, venous thrombosis, benign prostatic hypertrophy (BPH), pulmonary embolism (PE) and pulmonary infections. The patient was seen by his provider who noted that the patient has had ventilator dependent ALS for many years and has had round the clock care. The request is for 24 hours per day, 7 days per week of licensed skilled nursing services, which is under review.

This patient requires aggressive pulmonary toileting measures and is completely dependent on others for 24-hour care. The patient has also been receiving 24-hour care in the past and there has not been any improvement in his condition. 

The 24 hours per day, 7 days per week of licensed skilled nursing services are considered medically necessary for this patient. The patient requires 24-hour care due to his inability to move, need for repositioning and frequent pulmonary suctioning.

"Amyotrophic lateral sclerosis (ALS), also known as "Lou Gehrig disease," is a neurodegenerative disease of the motor neurons. No single etiology has been proven; rather, multiple pathways (both heritable and sporadic) have been shown to result in unmistakably similar disease entities. ALS necessarily affects both upper and lower motor neurons with variable patterns of onset, most commonly beginning with signs of lower motor neuron degeneration within proximal limbs. As it is a progressive disease, it will eventually lead to paralysis and, inevitably, death. There is no cure for ALS; however, multiple medications and interventions can reduce symptoms and prolong life, sometimes up to 10 or more years." (Brotman, R. G. et al. 2022).

"Our study is a randomized trial to evaluate the effect of a scheduled, enhanced oral-care intervention to prevent aspiration and reduce ventilator-associated events. The intervention includes deep oropharyngeal suctioning every 4 hours, along with the usual oral care provided to intubated patients." (Sole, M. L. et al. 2018).

"Skilled Nursing Facilities According to the Centers for Medicare and Medicaid Services, a skilled nursing facility is "a facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital." Individuals are discharged to a SNF(Skilled Nursing Facilities) when they no longer need care provided by a hospital but are unable to be sent home because they cannot get out of bed, move around, or use a wheelchair safely; have surgical wounds; or do not have adequate help at home. Like other long-term care facilities, SNFs provide assistance with activities of daily living, however SNFs also provide intravenous injections and physical therapy. These services are carried out by trained and licensed professionals (i.e., registered nurses and doctors). Personal care aides and CNAs(Center for a New American Security) are unable to perform these activities but assist with other duties. Other licensed professionals working at SNFs include physician assistants, nurse practitioners, physical therapists, occupational therapists, and speech language pathologists." (Heiks, C. et al. 2022). 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for 24 hours per day, 7 days per week of licensed skilled nursing services is substantiated.