Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ornithine Transcarbamylase (OTC) deficiency.
Treatment:  Private Duty Nursing services 24 hours per day.

The insurer denied coverage for Private Duty Nursing services 24 hours per day.  The denial is upheld.

The patient in an infant with a past medical history notable for ornithine transcarbamylase (OTC) deficiency status post liver transplant, hypotonia, developmental delay, seizure disorder and feeding difficulties status post gastrostomy/jejunotomy (GJT) placement. To address his medical needs, he had been receiving skilled nursing services 24 hours per day. 

The medical needs offered for justification of the requested services include:  1) Vitals 1-2 x per shift, 2) Global assessment, 3) GJT [gastrostomy-jejunostomy] care, 4) GJT medications, hydration and feeds, 5) Assistant with oral feeds, 6) Aspiration precautions, 7) Seizure precautions, 8) Skin integrity, assessment and care, 8) orthotic splitting 4 x (times) per day, 9) Oral suctioning of secretions, 10) Management of bladder and bowel incontinence, and 11) Assistance with activities of daily living.
 
He is permitted tastes of purees by mouth. He receives continuous GJT feeds with Peptomen Jr. at 50cc [cubic centimeter] x 16 hours per day. In addition, he receives five 50cc water boluses via JT [jejunostomy tube] throughout the day as well as flushes with medications before and after feeds. There is no weight documented in the materials submitted for review. His standing medications include citrulline BID [twice daily] GT [gastrostomy tube], cyclosporine BID GT, iron supplement daily GT, Keppra BID GT and Prevacid BID GT. In addition, his medications available as needed include Tylenol, Diastat, simethicone, Miralax, Oragel, normal saline nebs and various topical skin care agents (triamcinolone, chloroplast). He non-ambulatory and non-verbal.  He receives PT [physical therapy], speech and feeding therapy. He lives with his mother (with multiple active medical issues of her own) and his father, who is working. He is followed by a multidisciplinary team including neurology, gastroenterology/ nutrition, transplant hepatology, genetics/metabolic and primary medicine. He is incontinent of stool and urine.
  
This patient appears to have infrequent clinical seizures managed well on his current medication regimen. His caregivers certainly have the ability to administer the available prn (as needed) medications as above and supplemental oxygen while awaiting EMS [emergency medical services] if seizures are prolonged, even without skill nursing in attendance.
 
Although there were no swallowing studies submitted for review this child seems at significant risk of aspiration during feeds (16 hours per day). He seems to take minimal by mouth if anything. Although requiring GJT continuous feeds he appears to tolerate them well with occasional vomiting without respiratory compromise. He has no reported distention, abdominal pain or residuals. There are no reported recurrent pneumonias, impaired oxygenation or frequent deep suctioning that appears mitigated by appropriate precautions. The overall complexity of his current care plan is such that it is reasonable to expect a well-trained non-medical caretaker to provide some of the current allocated care needs without skilled nursing present. This patient will continue to receive all of the current skilled nursing services in 20 hours allotted. 
 
This patient's medical condition and care needs do not meet standards for medically necessity for 24 hours of private duty nursing per day. His chronic medical conditions and chronic care needs appear stable and within the family's ability to provide safely meriting a reduction in hours of skilled nursing coverage. It appears unlikely that a 4-hour reduction in skilled nursing daily would create overwhelming burden on the family or jeopardize this patient's overall health status. Periodic adjustments in this patient's treatment plan will continue to occur guided by his chronic multidisciplinary treatment team. 

Uphold denial of coverage for 24 hours per day x 7 days per week of Private Duty Nursing. The approved 20 hours per day, 7 days per week noted by the insurer is sufficient to meet the needs of the patient. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Private Duty Nursing services 24 hours per day is upheld. Medical Necessity is not substantiated.