Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tetralogy of Fallot

Treatment: Skilled shift nursing in the home 96 units per day x 7 days per week (24 hours per day x 7 days per week)

The insurer denied coverage for skilled shift nursing in the home 96 units per day x 7 days per week (24 hours per day x 7 days per week).

The denial is overturned.

According to the medical records, the patient is an infant who has many medical problems.  The patient had Tetralogy of Fallot (TOF) which is a severe congenital heart problem.  The patient had surgery for this but needs more surgery to provide a more complete correction.  The patient has had a complex course. The patient had been discharged from the hospital then readmitted just 5 days later due to cardiac deterioration and had 2 cardiac arrests as well as the need for extracorporeal membrane oxygenation (ECMO).  The patient was discharged again two months later. The family has 9 children, so the patient's mother cannot monitor the patient 24 hours daily by herself, since the mother must also watch her other children. The patient is fed by nasogastric tube (NGT) and is at risk for aspiration as demonstrated by an abnormal swallow study.  Now at home, the patient's parents are requesting 24-hour nursing care.

This patient is at very high risk for abrupt and severe decompensation, so they require 24-hour daily monitoring. Therefore, denial of this coverage is not in the best interest of the patient.      

Skilled shift nursing in the home 96 units per day x 7 days per week (24 hours per day x 7 days per week) is considered medically necessary for this patient.

The patient is very fragile. The patient's heart still needs further surgery, so it is not yet functioning 100% (percent) normally.  The patient is NGT fed and at risk of aspiration, which will cause abrupt deterioration and lead to another hospitalization. The patient has pulled out the NGT frequently, so there needs to be skilled nursing to prevent the dislodgement as well as for replacing the NGT in the event that it does become dislodged.  The patient needs to gain weight and strength so that they can be fit for their next surgery. The patient is at risk for aspiration, so close monitoring 24-hours daily is necessary. Chest physical therapy is also necessary. The patient has had blood clots and has received Lovenox. The patient remains at high risk for more clots.

Any infection, including a "minor" viral infection can tip the patient condition into deterioration, so protecting the patient from the 8 siblings who could bring illness into the home is very important. The family has 8 other children, so the parents cannot monitor this patient for the necessary 24-hours daily that the patient needs. The 24-hour nursing will allow the parents adequate rest and support their physical, emotional and psychological health, so they can manage this patient and their siblings.

Overall, the patient is at high risk for sudden deterioration and this nursing care will prevent such events and prevent further hospitalizations.

                                  
Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for skilled shift nursing in the home 96 units per day x 7 days per week (24 hours per day x 7 days per week) is substantiated.