Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adrenal Insufficiency, Hypothyroidism, Hyponatremia
Treatment: Skilled Private Duty Nursing 24 hours per day, 7 days per week
The insurer denied the skilled private duty nursing 24 hours per day, 7 days per week.
The denial is upheld.

The patient is a male teen with medical history significant for adrenal insufficiency, hypothyroidism, hyponatremia, chronic hepatitis, gastroesophageal reflux, feeding intolerance status post gastrostomy tube placement and dependence, chronic constipation, asthma, allergic rhinitis, obstructive sleep apnea, obstructive hydrocephalus status post VP (ventriculoperitoneal) shunt placement, refractory seizure disorder, obesity, idiopathic kyphoscoliosis, congenital hip dislocation, and temperature instability. He is globally severely developmentally delayed. He is incontinent of bowel and bladder. He is non-ambulatory and visually impaired. He requires suctioning and supplemental oxygen as needed. He receives breathing treatments and airway clearance. He has BiPAP (bilevel positive airway pressure) available as needed for obstructive sleep apnea. His gastrostomy tube feedings with Pedialyte and free water apparently are administered at a rate of 100 mL/hour or via bolus. He receives physical therapy three times a week, speech therapy twice a week, and occupational therapy twice a week. 

He lives at home. There is no indication from the documentation that there are no adult caregivers available in his home. 

Skilled nursing needs include the following: gastrostomy tube care and feedings, monitoring of fluid intake and output, airway management with suctioning and application of supplemental oxygen and BiPAP (bilevel positive airway pressure) as needed, medication administration including breathing treatments, maintenance of seizure precautions, maintenance of aspiration and reflux precautions, maintenance of skin integrity (especially due to obesity), close monitoring of vital signs due to temperature instability, and total management of all activities of daily living.

This male adolescent patient has numerous medical issues as a result of and in addition to his adrenal insufficiency and seizure disorder as detailed above. He currently does not have an artificial airway, but requires skilled decision-making for application of BiPAP and supplemental oxygen during periods of worsening obstructive sleep apnea and hypoxia. In addition, he requires close monitoring of his fluid intake and output because there is some variability in his fluids complicated by history of hyponatremia. With adrenal insufficiency it is imperative that periods of stress are recognized and treated immediately with stress doses of hydrocortisone to prevent circulatory collapse. It is not always possible for trained layperson caregivers to make the determination particularly when the usual support systems are not available (for example, at night). Based on the documentation provided, he requires skilled nursing care. However, he does not require round-the-clock skilled nursing care. It is not unreasonable to expect trained layperson caregivers to provide for his needs for periods of time during the day without endangering him in any way or placing him at risk of morbidity. The requested private duty nursing 24 hours per day 7 days per week is not medically necessary, based on the documentation provided.