Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Seizure Disorder
Treatment: Private Duty Nursing: 24 Hours Per Day, 7 Days 
Per Week, shared by RN and LPN (4320 units) - by RN
The insurer denied: Private Duty Nursing: 24 Hours Per Day, 7 Days Per Week, shared by RN and LPN (4320 units) - by RN
The denial is partially overturned.

The patient is an adolescent male child with medical history significant for viral encephalitis, Lennox-Gastaut seizures status post vagal nerve stimulator placement, gastroesophageal reflux disease with dysphagia status post gastrostomy tube placement and dependence, eczema, and intermittent asthma. He has multiple breakthrough seizures every day, up to ten, often with associated desaturation that resolves with repositioning. He has difficulty managing secretions, requiring frequent suctioning. He is non-verbal, wheelchair dependent, unable to communicate wants and needs, and lacking safety awareness. Medications include Banzel, clobazam, Epidiolex, Keppra, glycopyrrolate, phenobarbital, and rufinamide. He receives three gastrostomy tube feedings daily. He is incontinent of bowel and bladder. 
The patient lives with his mother and father. Both parents work outside of the home to support the family. His mother works part-time, and his father works full-time including nights. His mother is his primary caregiver. She has developed a chronic pain condition that requires injections and physical therapy. The patient attends a special education school Monday through Friday, and he receives therapies multiple times a week (physical therapy [PT] three days per week, occupational therapy [OT] three days per week, speech therapy [ST] four days per week).
Skilled nursing needs include gastrostomy tube care and feedings, administration of small amounts of soft foods by mouth as tolerated, maintenance of reflux and aspiration precautions, maintenance of seizure precautions with administration of supplemental oxygen as needed for desaturations, suctioning and airway clearance, monitoring of pulse oximetry during sleep with administration of supplemental oxygen as needed, medication administration including breathing treatments and routine medicines and as needed medicines, incontinence care, skin integrity assessment and monitoring for breakdown and eczema flares, monitoring vagal nerve stimulator (VNS) with activation as needed, and performance of all activities of daily living.

The skilled nursing services 24 hours per day, seven days per week, are medically necessary and appropriate. The services can be provided by a licensed practical nurse (LPN) with registered nurse (RN) oversight and site visit every two to four weeks to address any changes or concerns.

This male child has significant disability as a result of and in addition to his refractory seizure disorder, with skilled nursing needs as noted above. The patient requires constant monitoring and assessment for changes in his condition. He cannot be left alone because of his breakthrough seizures, reflux, scratching his face and rubbing his eyes, and restlessness. The patient receives medications every couple of hours routinely and as needed. Transfers often require two people, particularly with the gait trainer. This level of care is above and beyond what trained layperson caregivers can safely provide. It is reasonable for trained layperson caregivers to assist in the patient's care, but the patient really requires the skill and expertise of private duty nursing round-the-clock. Up to this point, the patient has been receiving 24 hours per day of private duty nursing. This has been very successful in keeping the patient out of the hospital and the emergency room. Ongoing skilled nursing services 24 hours a day, seven days a week, remain medically necessary for this child. These services can be safely provided by a licensed practical nurse (LPN). Registered nurse (RN) services would be reasonable and appropriate once every two to four weeks to address any concerns or changes.