Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchopulmonary Dysplasia; failure to thrive
 
Treatment: 16 hours of PDN, 7 days per week

The insurer denied coverage for 16 hours of PDN, 7 days per week. The denial is reversed. 

This patient is a male child who was born at 27 weeks gestation with a complicated congenital heart condition.  The child had transposition of the great arteries, a ventriculo-septal defect (VSD), pulmonic stenosis, and has had 2 previous cardiac surgical procedures.  The post op course was complicated by a cardiac arrest, seizures, adrenal insufficiency and failure to thrive.  The child is also diagnosed as having Bronchopulmonary Dysplasia and requires treatment with Flovent and continuous oxygen supplementation.  The child is at risk to aspiration and is fed by a Gastrostomy tube. The insurer has ruled that this patient's medical condition does not require ongoing home nursing services at 16 hours per day, but they did decide that 12 hours per day 7 days per week would be sufficient to meet all the care needs for this patient.  
According to Uptodate, Complications and long-term pulmonary outcomes of bronchopulmonary dysplasia, "Despite important advances in perinatal care and a steady decline in mortality rates among very low birth weight (VLBW) infants (<1500 g) during the past two decades, bronchopulmonary dysplasia (BPD) remains a major complication of premature birth and is a significant cause of long-term morbidity.  Prematurity and low birth weight remain major risk factors for the development of BPD [1].  Other contributors to the development of chronic lung injury include swallowing dysfunction and poor nutrition, which are common comorbidities in infants born very prematurely.  Because of its chronic nature and multifactorial causes, many infants and children with BPD will require multifaceted and multidisciplinary management well beyond the first year of life.  There are no established guidelines for the management of BPD after initial discharge from the hospital. Pulmonary hypertension - Pulmonary hypertension (PH), a condition characterized by elevated pulmonary artery pressure, develops in 20 to 40 percent of infants with BPD.  The risk for PH is highest in very premature and VLBW infants, as well as those with cardiovascular anomalies.  At a minimum, all infants with moderate or severe BPD should be screened for PH using echocardiography.  Earlier screening should be performed for selected infants with severe respiratory symptoms or risk factors, or if an anesthetic procedure is planned, because PH is associated with increased risk of life-threatening complications during anesthesia."

This patient is a medically complex child with ongoing skilled nursing care needs which include supervision of gastrostomy tube feedings, suctioning of airway secretions, and monitoring a developmentally delayed child.  This patient's medical condition and care needs require ongoing skilled nursing services in the home at 16 hours per day/7days per week.  The physicians caring for this child would be most suited to evaluate the ongoing skilled nursing care needs in the home and they have documented the ongoing care needs. 

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

The carrier's denial of coverage for 16 hours of private duty nursing services for seven days a week is reversed.  The medical necessity substantiated.