Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure disorder and dysphagia. 

Treatment: Consumer Directed Personal Assistance Services (CDPAS)

The insurer denied coverage for CDPAS. 

The denial is overturned. 

This patient is a female child whose main issues are refractory seizure disorder (on multiple anti-epileptics) complicated by multiple hospitalizations, newly diagnosed dysphagia and nasogastric tube (NGT) dependence with an ongoing need for seizure precautions and administration of nasogastric (NG) feedings. The patient requires care related to activities of daily living (ADLs) and need for observation and positioning during and after NG feedings as part of aspiration precaution protocol given her global delay and neurological compromise. Based upon documentation provided, the patient has a need for at home care services.

A study published in Pediatrics regarding medically complex children who received post-hospital discharge home health services (compared with children who did not receive home health services following hospital discharge) demonstrated lower readmission rates among those receiving services. (1) As the acuity of hospitalized children has increased over time, so has the severity and complexity of the unresolved medical conditions present on discharge.(2) Children are now frequently sent home to complete or continue interventions that formerly would formerly have occurred in hospitals including technology dependence such as upon enteral feeding pumps with significant nursing dependence for observation, feed titration, and positioning such as in this child.

One of the serious risks of reflux disease in children lacking sufficient airway protection is aspiration of gastric contents and recurrent pulmonary infection. Chronic pulmonary aspiration, a type of lung injury caused by intermittent or persistent contamination of the airways with oral and/or gastric content, occurs when the normal airway protective mechanisms are impaired, bypassed, or overwhelmed.(3) The consequences of injuries may include bronchospasm, atelectasis, pulmonary edema, pneumonia, and/or bronchiectasis.(4)

This patient has dysphagia in the setting of refractory seizure disorder and congenital cytomegalovirus (CMV) placing her at a significant risk for aspiration. Per reviewed records, it does not appear that patient had an actual episode of aspiration. There is no documentation whether modified barium was completed to assess aspiration. Per Medical Doctor note, the patient is safe for honey thickened or puree only. This is likely secondary to failing oral challenge with all other consistencies.  

Hospitalized children with complex chronic conditions, which includes technology dependence, who were discharged to home health care experienced fewer short-term readmissions, subsequent hospitalizations, and lower hospital costs over a 12-month period versus those not receiving home health care.(1)

Consumer Directed Personal Assistance Program (CDPAP) eligibility: Consumers must require assistance with ADLs or skilled care, have a stable medical condition, and be self-directing  or have a designated representative that is willing and able to direct care as per the program's requirements. Since CDPAP is a Medicaid sponsored program, it is only available to consumers that are eligible for Medicaid. (5)

The evidence provided strongly supports provision of adequate care for this child. This child is unable to perform the necessary tasks expected for her age given her disabilities and would benefit from skilled care given recent diagnosis of dysphagia and need for NGT feedings to ensure her safety and protect her from further decline and hospitalizations. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for an initial request for Consumer Directed Personal Assistance Services (CDPAS) is overturned. Medical necessity is substantiated.