Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anoxic brain injury secondary to malignant hypertension, static encephalopathy, seizure disorder, visual impairment, dysphagia, chronic kidney disease secondary to renal artery stenosis, and hypertrophic cardiomyopathy
Treatment: S9124-Nursing Home Care In the Home (by LPN per hour) For 16 Hours per Day
The insurer denied the S9124-Nursing Home Care In the Home (by LPN per hour) For 16 Hours per Day
The denial is overturned.

The patient is a male child with medical history significant for anoxic brain injury secondary to malignant hypertension, static encephalopathy, seizure disorder, visual impairment, dysphagia, chronic kidney disease secondary to renal artery stenosis, and hypertrophic cardiomyopathy. He is non-ambulatory, non-verbal, and incontinent of bowel and bladder. His epilepsy is intractable, with frequent daily seizures round-the-clock associated with emesis. He is dependent upon gastrostomy tube feedings, but has difficulty tolerating, with frequent vomiting and discomfort. He requires frequent venting. He has severe sleep-wake disturbance and can be awake for days at a time despite medication management. He is evidenced to be inconstant pain, often crying. He has poor airway protective reflexes necessitating oral suctioning and airway clearance treatments. He has frequent and unpredictable episode of oxygen desaturation, requiring administration of supplemental oxygen. He is fully dependent upon caregivers for all activities of daily living.

The patient lives with his parents and two siblings. He attends school where he receives comprehensive rehabilitation services. He has nursing attend him while at school. His treatment team involves Neurology, Pulmonary, Cardiology, Primary Care, and Orthopedics.

The patient's skilled nursing needs include gastrostomy care and administration of feedings, maintenance of aspiration and reflux precautions with suctioning of vomitus as needed, performance of airway clearance techniques, oral and nasal suctioning as needed, monitoring pulse oximetry with administration of supplemental oxygen as needed, maintenance of seizure precautions with administration of rescue medications as needed, close monitoring of blood pressure due to history of malignant hypertension, monitoring for acute on chronic pain with appropriate interventions, and performance of all activities of daily living.

Yes, the requested 16 hours/day 7 days/week of skilled nursing services are medically necessary and appropriate.
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 male child has a number of disabilities and medical issues as a result of his anoxic brain injury and chronic kidney disease as described above. His care is extremely involved, with constant monitoring of numerous systems and performance of appropriate interventions as needed. He requires round-the-clock active monitoring. Based on his level of care and need for constant evaluation and intervention, he requires skilled nursing services to prevent further morbidity. It is appropriate for his parents to remain involved in his care, but they alone are not sufficient to provide the level of care that he requires for more than 8 hours per day. The requested 16 hours daily 7 days a week of skilled nursing services remains medically necessary and appropriate.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.