Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchopulmonary Dysplasia. 
Treatment: Private duty nursing (PDN) 16 hours per day, 7 days per week split between 3 independent nurses. 
The insurer denied coverage for private duty nursing 16 hours per day, 7 days per week split between 3 independent nurses. 
The denial is overturned. 
 
The insurer seeks to decrease the skilled home nursing services from 16 hours per day to 12 hours per day 7 days per week for this toddler. The insurer has ruled that this patient's medical condition does not require continuation of the additional 4 hours of home nursing services and that the child's medical condition does not require nursing supervision during the day when the child is awake. All of the medical records submitted were reviewed, consisting of the skilled nursing care agency medical record, the information from the insurer and the medical chart from the pediatric pulmonologist who has been caring for this child. 

This is a toddler who was born premature at 27 weeks gestation and has a diagnosis of Bronchopulmonary Dysplasia and pulmonary Hypertension. The child has a tracheostomy tube, which can be capped during the day for several hours without any increased respiratory effort or hypoxemia. The medical record also indicates that the child tolerates a Passey Muir valve over the tracheostomy tube for 2-3 hours during the day. He sleeps throughout the night with no hypoxemia. The home nursing record is not clear if the child has been using an oxygen concentrator or the ventilator when sleeping but the pediatric pulmonologist notes recommend the ventilator be available for use when the child is sick and in need of additional respiratory support. The child receives occupational therapy (OT), physical therapy (PT) and speech therapy (ST). He receives Flovent with a metered dose inhaler and albuterol twice a day and is continued on sildenafil three times per day via a gastrostomy tube. He receives gastrostomy tube feedings. There has been no recent evidence of illness requiring emergency room (ER) visits or hospitalization. 

The insurer has determined that the skilled home care nursing services can be decreased from 16 hours per day 7 days per week to 12 hours per day 7 days per week. 

The mother has requested an expedited review to determine whether the services can be maintained at the current 16 hours per day 7 days per week. 

Private duty nursing (PDN) 16 hours per day, 7 days per week split between 3 independent nurses is considered medically necessary for this patient. 

The patient has ongoing skilled home nursing care needs but the medical record and the home nursing record documents that the child has continued to be stable medically with no acute respiratory problems and that his condition has continued to improve since he was no longer requiring the ventilator six months ago. The child has not required any hospitalization or ER visits for respiratory illness and the child has tolerated weaning off the ventilator and tolerates capping of the tracheostomy tube during the day. 

In order to facilitate the necessary medical visits and to monitor the child during the weaning process, the skilled home nursing services should be continued at the current 16 hours per day 7 days per week. This will allow the nursing team to monitor the child as the medical support services in the home are weaned with close supervision by the pediatric pulmonologist. 

Decisions concerning the ongoing need for skilled home nursing services will be best determined by consultation with the patient's medical team who oversee the child's chronic medical condition and have ordered the home nursing care to help maintain his health and avoid need for hospitalization. 

Based on the above, the insurer's denial is reversed. 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 private duty nursing (PDN) 16 hours per day, 7 days per week split between 3 independent nurses is substantiated.