Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular Disorder
Nursing Services (including Private Duty Nursing)

The patient is a male child that suffered severe anoxic brain injury at birth status post cool cap for 72 hours; now with hypoxic ischemic encephalopathy, Pierre Robin Sequence, congenital disorder of glycolsylation type 1T (PGM1), possible seizure disorder, and global developmental delay. He was hospitalized in the Neonatal Intensive-Care Unit (NICU) for two months and then transferred. Despite treatment with a galactose supplement, he continues to have elevated transaminases, feeding disorder with dysphagia and sensorimotor feeding disorder, severe acid reflux with frequent vomiting requiring suctioning, severe obstructive sleep apnea, and moderate to profound hearing impairment. He is fed intermittently via gastrostomy tube during the day and continuously overnight. He is able to take a minimal amount of food and fluids by mouth, but not enough to sustain himself. He remains at significant risk for aspiration. He lives at home with his parents, both of whom are involved in his care. Skilled nursing needs include the following: gastrostomy tube care and feeding, oral feeding as tolerated, maintenance of aspiration and reflux precautions, monitoring for seizure-like activity, medication administration (both oral and respiratory, routine and as needed), monitoring for respiratory distress including pulse oximetry, maintenance of patient safety, suctioning as needed for vomiting to prevent aspiration, and assistance with all activities of daily living above and beyond what is needed for a typical child.

The health plan's determination is overturned. The the Skilled Nursing Care in the Home: up to 10 Hours per Day/7 Days per Week is medically necessary for this patient.
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." Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." 
This medically fragile male child has numerous medical problems as a result of and in addition to hypoxic ischemic encephalopathy and his rare congenital metabolic disorder. Virtually every system is involved, and he requires constant supervision and intervention to maintain health and prevent morbidity. He requires round-the-clock care because of projectile vomiting requiring suctioning and re-administration of medications, respiratory care with nebulized medications, and continuous feedings overnight to prevent aspiration and further illness. While his parents are able to participate in his care, it is neither safe nor reasonable to expect them to provide the level of care that he requires round-the-clock. The requested skilled nursing care 10 hours daily 7 days a week is medically necessary given the potential for further complications.