Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenital bilateral vocal cord paralysis, severe tracheomalacia, severe
subglottic stenosis status post cricoid split with posterior airway scarring,
gastroesophageal reflux, moderate malnutrition, and feeding intolerance
Treatment: Skilled Shift Nursing 24 hours/day, 7 days/week
The insurer denied the Skilled Shift Nursing 24 hours/day, 7 days/week.
The denial is overturned.

The patient is a female child with congenital bilateral vocal cord paralysis, severe
tracheomalacia, severe subglottic stenosis status post cricoid split with posterior
airway scarring, status post tracheostomy tube placement for worsening stridor,
now with critical airway. She also has gastroesophageal reflux, moderate
malnutrition, and feeding intolerance, receiving all nutrition and fluids via
gastrostomy tube. She receives feedings over an hour during the day, and
continuous at night for 12 hours. She is otherwise developing neurologically in an
age-appropriate manner.

The patient lives with her parents and three-year-old sibling. The child's mother was
recently diagnosed with an aggressive oral cancer, adenoid cystic carcinoma, with
surgical removal of her palate and multiple teeth. She requires opiate medications
to manage the pain. She is now undergoing chemotherapy and radiation therapy,
and she is physically unable to manage the care of her children. The child's father
has been functioning as primary caregiver, along with 16 hours daily of skilled
nursing services, sacrificing sleep to care for the family. However, he recently had
to return to work because of risk of losing his job. He is no longer available at home
to care for his children.

The patient's skilled nursing needs include constant monitoring and supervision for
any indication of dislodged tracheostomy tube due to the child's critical airway,
tracheostomy tube care and frequent suctioning, gastrostomy tube care and
feedings with five feedings over an hour during the day and continuous feedings
over twelve hours at night, management of nightly BiPAP/CPAP (bilevel positive
airway pressure/continuous positive airway pressure), maintenance of aspiration
precautions, monitoring of continuous pulse oximetry with application of
supplemental oxygen as needed, monitoring of end-tidal CO2 (carbon dioxide),
medication administration, and performance of all activities of daily living.

Yes, the Skilled Shift Nursing 24 hours/day, 7 days/week is medically necessary.

According to the American Academy of Pediatrics Guidelines for Home Care of
Infants, Children, and Adolescents With Chronic Disease, "comprehensive planning
should minimize physical and emotional risk to the patient, adverse effects on
family members, or unforeseen financial burdens." (1) Further, "the goal of a home
health care program for infants, children, or adolescents with chronic conditions is
the provision of comprehensive, cost-effective health care within a nurturing home
environment that maximizes the capabilities of the individual and minimizes the
effects of the disabilities." (1)

This young female child was born with bilateral vocal cord paralysis and severe
tracheomalacia, with subsequent severe subglottic stenosis status post cricoid split
complicated by posterior scarring now status post tracheostomy tube placement.
She has airway obstruction requiring non-invasive ventilatory support with
BiPAP/CPAP during sleep. She requires frequent suctioning to prevent airway
obstruction. She is awaiting additional surgical reconstruction of her airway, but for
now has a severely critical airway. In addition, she has severe gastroesophageal
reflux and is dependent upon gastrostomy tube feedings for all nutrition. Despite
tube feedings and medications, she is at risk for aspiration because of the severity
of her reflux. Finally, she is neurologically intact, developing into a curious toddler
with the potential for dislodging her tracheostomy tube with risk of acute respiratory
failure and suffocation.

This young child requires constant supervision round-the-clock with skilled
intervention to prevent loss of her airway in addition to her other skilled needs.
While it is not unreasonable to expect layperson caregivers to assist in the care of
this young child, they do not have the skills or experience needed to truly maintain
her safety, particularly now with the mother's cancer and the father's return to work.
This young child requires round-the-clock skilled nursing services 24 hours daily 7
days a week to prevent potentially devastating complications and allow for growth
and development. To provide less than this is to place this child at great risk of
morbidity and even mortality.