Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Tetralogy of Fallot, feeding intolerance and gastroesophageal reflux status post gastrostomy tube placement, seizure disorder, hypercholesterolemia, and global developmental delay. 
Treatment: Level 1:  Continued Private Duty Nursing Services - 7 days x 12 hours. 

The insurer denied the Level 1: Continued Private Duty Nursing Services - 7 days x 12 hours.  The denial is overturned. 

The patient is a female child with medical history significant for Tetralogy of Fallot pending additional surgical intervention, feeding intolerance and gastroesophageal reflux status post gastrostomy tube placement, seizure disorder, hypercholesterolemia, and global developmental delay.  She has history of severe dental caries.  There is some concern about maternal non-compliance.  She takes anticonvulsant medication and uses a nebulizer for breathing treatments.  She is non-verbal except during therapy. 

She lives with her parents and three siblings.  She receives home based therapies, including speech therapy once a week.  There is no information about school or parent work schedules. 

Skilled nursing needs include gastrostomy tube care and feedings, medication administration including enteral and inhaled routine and as needed medications, maintenance of seizure precautions, maintenance of aspiration and reflux precautions, and assistance with all activities of daily living above and beyond what would normally be needed for a child this age. 

Yes, the proposed treatment of Level I: continued private duty nursing 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 child has a number of medical issues as a result of and in addition to her congenital heart disease and seizures.  Her skilled needs include gastrostomy tube care and feedings, medication administration including enteral and inhaled routine and as needed medications, maintenance of seizure precautions, maintenance of aspiration and reflux precautions, and assistance with all activities of daily living above and beyond what would normally be needed for a child this age.  Of particular concern with this child is the question raised about compliance.  She has not completed her cardiac repair and retains her gastrostomy tube until that second surgery has been completed.  She is at risk for significant morbidity at this time in addition to further developmental delay.   Based on the records submitted, her clinical history, and the current standard of care, ongoing skilled nursing services 12 hours daily, seven days a week, are medically necessary and appropriate.