Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mitochondrial disorder

Treatment: Private Duty Nursing services 24 hours per day, 7 days a week

The insurer denied coverage for Private Duty Nursing (S9123), 24 hours per day, 7 days a week

The denial is overturned.

The patient is a female child with a PAX2 genetic mutation which causes a mitochondrial disorder.  The patient also has chronic kidney failure and required a kidney transplant in the past.  The patient has been receiving skilled home nursing services at 14 hours per day 7 days per week.  The patient has developmental delay and refractory seizures.  The patient has required brain surgery to remove areas of the brain related to her seizures. The patient has had a recent prolonged and complex hospital admission.  During this hospitalization, the patient developed acute respiratory distress syndrome (ARDS), cardiac arrest and anoxic brain injury.  The patient's condition was further complicated by a superior vena cava thrombosis which resulted from a deficiency of protein S which required treatment with warfarin.  The patient also had toxic megacolon which required a colostomy to be placed.  The patient is fed by gastrostomy tube and also has a tracheostomy tube. The pediatric pulmonologists recommended that skilled nursing services continue to be required in the home 24 hours per day 7 days per week.  The physicians have documented her respiratory treatment plan, which included pulmozyme and hypertonic saline inhalation treatments, chest vest and cough assist therapy.  When sick, the patient also has a protocol in place to increase her respiratory support initially to continuous positive airway pressure (CPAP) and if there is no improvement to restart her ventilator support via the ventilator.  Upon discharge, the patient was started on skilled home nursing services at 24 hours per day 7 days per week.

The insurer has determined that the child's medical condition no longer requires skilled nursing services at 24 hours per day 7 days per week and can be decreased to 12 hours per day 7 days per week.

Based on the review of the medical record and literature, skilled nursing services 24 hours per day, 7 days per week is considered medically necessary for this patient. The patient has ongoing care needs related to her complex medical condition.  The patient is at risk for respiratory failure and requires therapy with a chest vest and a cough assist device to help mobilize her secretions.  The patient also has needs related to management of a tracheostomy tube and gastric tube feedings.  Based on review of the case and her complicated recent hospitalization, the skilled home nursing services are appropriate and required at the current rate of 24 hours per day 7 days per week.  The patient will need continued close follow up with her pediatric subspecialists to monitor her ongoing home care needs.  The insurer should continue to provide skilled home nursing services at 24 hours per day 7 days per week for a period of 3 months to ensure that her condition remains stable.  The physicians caring for this patient can then reassess her ongoing care needs and make recommendations for the fall and winter.

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

The carrier's denial of coverage for Private Duty Nursing (S9123), 24 hours per day, 7 days a week should be overturned.  The medical necessity is substantiated.