Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for private duty nursing services (CPT G0300  4320 units, CPT G0162  48 units). At issue in this case is whether the requested private duty nursing services (CPT G0300  4320 units, CPT G0162  48 units) are medically necessary to treat the patients condition for any of the following:to prevent disease, disability, and other health conditions or their progression;to prolong life;to promote physical and mental health and efficiency; orto correct or ameliorate any physical or behavioral conditions.The submitted documentation does not support that the requested services are medically necessary for any of the following reasons: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; or to correct or ameliorate any physical or behavioral conditions.Home based nursing services are essential for parents of children with life-limiting or life-threatening diseases who spend an average of nearly nine hours per day managing their childs basic healthcare needs, such as personal hygiene and feeding, administering intravenous drugs, and managing symptoms like seizures, pain, respiratory distress, secretion management and sleep related problems during the night. (Lazzarin, P., et al.) Current data shows that the number of medical appliances and the status of single caregivers correlated proportionally with a greater amount of time needed for the childs care. It is important for these families to receive appropriate support with daily care, through the evaluation of individual needs of the child and organization of care models. Based on the evidence from research, the time spent providing care in such cases is associated with the number of medical appliances used at home (when the number of medical appliances is less than five, versus five or more, the mean time taken to provide care is 6 versus 10 hours, and the time spent by a single caregiver compared with more than one caregiver is 10 versus 7 hours per day).In this case, the patient does not have multiple chronic conditions or life limiting diseases that make the child dependent on multiple caregivers and the use of complex medical appliances. There are no life sustaining medical devices used. In contrast with children who have incurable conditions and who need highly complex medical care that should be cared for at home, this patients quality of life may be adequately maintained without a 180-hour-per-month in home skilled nursing service. Quality data suggests that it is not so much the childs disease that determines the daily burden of care for the parents, but the number of different procedures that must be expertly managed. In this case, the amount of private duty nursing hours requested is not a medical necessity. Parents can be trained to provide gastrostomy tube feedings and care, and they can be educated on how to monitor for signs of distress. Accordingly, the requested private duty nursing services (CPT G0300  4320 units, CPT G0162  48 units) are not medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; or to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.