Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective Disorder.
Treatment: Skilled nursing visits, 5 visits.
The insurer denied Skilled nursing visits, 5 visits.
The determination is overturned.

The patient has a past medical history of chronic deep vein thrombosis (DVT), pulmonary embolism (PE), venous insufficiency, compression fractures, low back pain, constipation, osteoporosis, anemia, osteoarthritis, schizoaffective disorder, diastolic heart failure, hiatal hernia, benign positional vertigo (BPV), morbid obesity, chronic kidney disease, gastroesophageal reflux disease (GERD), coronary artery disease, diabetes mellitus type 2 with nephropathy, hypertension, hyperlipidemia, hypothyroidism, and cerebrovascular accident (CVA). A clinical registered nurse (RN) teaching visit noted the patient was receiving home health aide services 24 hours/day, 7 days/week and the nurse prepours medications into appropriate pillboxes.  The insurer sent an initial adverse determination denial notice denying coverage for 9 skilled nursing visits, but approving 4 visits. The denial stated 9 skilled nursing visits were not medically necessary and the patient no longer met criteria and the patient had made gains toward her home care goals with learning about her health condition, diet, and medications. The denial also stated the patient's caregivers, including personal care assistant (PCA), could assist the patient with blister pack medications provided by her pharmacy. The insurer provided a final adverse determination denial notice denying the request to approve additional 5 skilled nursing visits. The family appealed the denial decision. The family provided form managed long term care (MLTC) 229 stating the patient's life was in danger if the visiting nurse providing medication management was not continued. The family noted in this form that blister packs by the pharmacy could not meet the patient's needs.
The patient's daughter provided a letter appealing the denial decision stating the patient's life was in danger because she was not competent to make necessary changes to her many medications which were currently poured each month in her home by a visiting nurse. The daughter noted the insurer was forcing the patient to participate in a blister pack packaging and the daughter felt this would not work for her mother as the pharmacy would not adjust medication packs once they were dispensed and she would have to wait for changes in medication until the next month's refill. Her daughter also noted some of the patient's medications were controlled substances and psychotropic medications and the patient was in danger to pour her own medications. The patient's primary care physician (or provider) (PCP) provided a letter outlining the patient's medical conditions noting the patient has a very complicated medication list that requires frequent adjustment and changes due to her multiple active medical issues and she was not a good candidate for blister package due to multiple changes that still occur. The PCP letter also noted the patient got pain medications every 4-6 hours including at 2 AM and 6 AM. In addition, the letter stated the patient's regimen was actively adjusted and was being closely followed by a palliative care specialist. The PCP also noted the patient lived alone with limited family support and the patient could not manage her medication on her own. Lastly, the PCP noted removing the current nursing medication management treatment would be incredibly detrimental to her health and medical care as her current home health aides are not able to administer medication. At issue is the medical necessity of skilled nursing visits, 5 visits. 

Yes, the services are medically necessary.
There is documentation from the patient's PCP that the patient would not be a candidate for a blister pack of medications due to her complex medical history and complex medications and it was medically necessary for a nurse to manage the patient's medications. It is therefore necessary for the patient to have a skilled nurse to continue management of the patient's medication. As the PCP noted, personal care assistants are not able to administer medication. The patient does not have informal support from her family to help her with medication management. The PCP also documented the potential for harm to the patient if there was not a skilled nurse managing the patient's medications.