Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's disease, dysphagia, end stage renal disease (ESRD), coronary artery disease (CAD), peripheral artery disease (PAD) status post below the knee amputation (BKA), type II diabetes, hypertension and hyperlipidemia
Treatment: Private Duty Nursing (PDN) - 24 Hours per Day, 7 Days per Week, a Total of 168 Hour per Week, Pre-service
The insurer denied the Private Duty Nursing (PDN) - 24 Hours per Day, 7 Days per Week, a Total of 168 Hour per Week, Pre-service
The denial is upheld. 

This male has diagnoses of Parkinson's disease, dysphagia, end stage renal disease (ESRD), coronary artery disease (CAD), peripheral artery disease (PAD) status post below the knee amputation (BKA), type II diabetes, hypertension and hyperlipidemia.  He is appealing denial of private duty nursing (PDN) 24 hours per day, total of 168 hours per week.  

The clinical records show the patient was admitted with aspiration pneumonia requiring intubation.  Hospital course was complicated by subdural hematoma (SDH), peritonitis, candidemia, and septic shock.  The most current progress reports show the patient is stable.  His respiratory status is stable on a vent without adjustment of vent setting.  He is receiving tube feeds at ten cubic centimeters (cc) per hour.  Antibiotics have been completed.  The patient continues to receive  private duty (PD).  There is a note that anticipates discharge to a skilled nursing facility (SNF).  

Uniform Assessment System (UAS) evaluation performed shows moderately impaired cognition due to dementia, vision and hearing are impaired.  Functional status is bedbound and total dependence with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  The patient's daughter-in-law has been trained with dialysis.  The patient has a chronic left foot ulcer with gangrene and multiple pressure ulcers with two new pressure ulcers around his sacrum.  He has a nasogastric (NG) tube, trach and is vent dependent.  The daughter-in-law is to be trained on wound, trach and NG tube care.  He is incontinent of bowel and bladder.  

An appeal letter from the provider states the patient requires chronic peritoneal dialysis.  Appeal statement from the provider states the patient is unresponsive and does not follow commands.  Recommends 24 hour care of healthcare professional to manage vent, dialysis and feedings.  Appeal statement from New York state notes multiple hospital stays.  The patient would like to be discharged to home.  The family is being trained to assist with skilled needs.  It states the patient needs 24-hour per day private duty nursing (PDN).

No, the proposed treatment, Private Duty Nursing (PDN) - 24 Hours per Day, 7 Days per Week, a Total of 168 Hour per Week, is not medically necessary.
Medically necessary services are those which are:
-	Safe
-	Effective
-	Generally accepted national standard of medical practice
-	Not provided primarily for convenience of the patient or the practitioner
-	The least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is not medically necessary because it is not consistent with generally accepted national standard of medical practice.

Private duty nursing is medically necessary for continuous, substantial and complex hourly nursing services provided by a licensed nurse in the patient's home.  Private duty nursing is hourly, skilled nursing care provided 24 hours per day on a one-to-one basis.  Private duty nursing is not indicated for maintenance care including:  administration or set up of oral medications, routine enteral feedings, routine colostomy care, intermittent straight urinary catheterization, or suctioning of the tracheostomy or ventilator maintenance of a stable patient.

This patient has multiple chronic conditions.  He is currently vent dependent after recent hospitalization for pneumonia, dialysis dependent and dependent on tube feedings.  He is bedbound, nonverbal and does not follow commands.  He has been stable on his current vent settings.  His peritoneal dialysis scheduled has been established.  His tube feeding have been established.  He has pressure ulcers, but does not require complex wound care.  He is clinically stable.  The care he is receiving is consistent with maintenance care.  He does not require hourly, skilled nursing care 24 hours per day on a one-to-one basis.  The proposed Private Duty Nursing (PDN) - 24 Hours per Day, 7 Days per Week, a Total of 168 Hour per Week is not medically necessary.