Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder. 
Treatment: 14 hours a day 7 days a week of private duty nursing care. 

The insurer denied the request for14 hours a day 7 days a week of private duty nursing care. 

The health plan's determination is upheld. 

The patient is a male who was born prematurely at 25 weeks' gestation. His birth weight was 1 pound 2 ounces. He has a history of chronic lung disease with pulmonary hypertension. Records were provided to the reviewer that describe that he has autism spectrum disorder, cognitive impairment and a ventriculoperitoneal shunt for hydrocephalus. He is fed by a gastrostomy tube, with intermittent feeds 6 times daily. He wears diapers. A letter from his mother describes that the patient has food aversion. He has difficulty following simple commands. His sleep is disturbed. He is in a special education class at school. The patient receives occupational, physical and speech therapy at school. The patient's mother and one of his siblings have diabetes. The patient has been approved for 10 hours of private duty nursing 7 days a week. 

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. 

The requested health service/treatment of private duty nursing for 14 hours a day, 7 days a week, is not medically necessary for this patient. The patient has been approved for 10 hours a day of private duty nursing 7 days a week; medical necessity is not met for an additional 4 hours a day of private duty nursing. 
The American Academy of Pediatrics Section on Home Health Care. Guideline for pediatric home health care, 2nd edition [1,2]. Home nursing is recommended for children with medical needs in Level 1. 
Level 1: Medically Complex: 
-Ventilator dependent, 
-Tracheostomy, 
-Need for recurrent or frequent suctioning, 
-Oxygen therapy in connection with apnea monitoring, 
-Maintenance of intravenous therapy including indwelling catheters, 
-Nutritional support-continuous nasogastric or gastrostomy tube feeding, central line.
Level 2: Intermittent Skilled, 
-Aerosol treatment with postural drainage, 
-Nutritional support-intermittent nasogastric or gastrostomy tube feeding, 
-Dressing changes, 
-Daily injection therapy, 
-Intravenous therapy-intermittent medication therapy, 
-Oral medication therapy, 
-Feeding program therapy, 
-Monitored diet. 
Level 3: Continuous Skilled Monitoring 
-Apnea monitor without oxygenation, 
-Seizures.

The patient has been approved for 10 hours per day, 7 days per week, of private duty nursing by the health plan. He does not have any of the conditions listed in the Level 1 criteria that might make an additional 4 hours of private duty nursing medically necessary. He is not ventilator dependent, and he does not have a tracheostomy.
The patient does not have the need for recurrent or frequent suctioning, nor is he on oxygen therapy in connection with apnea monitoring. The patient is not on intravenous therapy and he does not have indwelling catheters. He is not on continuous nasogastric or gastrostomy tube feeding, and he does not have a central line. 

The health plan's determination of medical necessity is upheld in whole.