Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Feeding/swallowing issues, oral motor deficits, poor oral intake, safety issues, and risk for aspiration
Treatment: Continued home care services (1 skilled nursing visit and 8 speech therapy visits)
The insurer denied coverage for continued home care services (1 skilled nursing visit and 8 speech therapy visits)
The denial is upheld

This case involves a patient diagnosed with osteogenesis imperfecta, scoliosis, repaired cleft palate, and disordered calcium metabolism. The information provided for the review noted the patient had multiple medical problems to include feeding/swallowing issues, oral motor deficits, poor oral intake, safety issues, and was at risk for aspiration. The patient has continued to display steady progress towards speech therapy goals but continued to present with reduced oral intake of nonpreferred food items throughout mealtimes and was inconsistent in oral intake of an increased volume. She presented with reduced overall strength of oral structures, which impacted her mastication skills of solid foods. At baseline, the patient had consumed about 5-10 bites (approximately 0.05 ounces of nonpreferred food items) and was currently observed consuming 15-20 bites for the same approximately 1 ounce of nonpreferred food items). This was considered a consistent and speech therapy sessions recommended to continue to improve oral motor skills for mastication of solids and to desensitize gag reflex. Short-term goals were established, and the patient's home exercise program was reinforced. The recommendation was for continuation of speech therapy services 1 time a week for improving strength and oral structures for mastication of solids, to continue improving overall volume of oral intake of a variety of food items to expand the patient's food repertoire, and to prevent regression of functional skills for eating. The patient received a notice of adverse determination stating that the request for 1 skilled nursing and 8 speech therapy visits was not medically necessary. The additional visits did not support a skilled plan of care and did not meet Milliman care guidelines. The patient was considered medically stable, was not documented declining condition, with claims that she made gains towards home care goals with learning about her health care condition, diet, and medications. This review pertains to the denial of coverage for continued home care services (1 skilled nursing visit and 8 speech therapy visits).  

Medical literature has noted that in children and adolescents who have medical complexities oftentimes benefit from home health care services, as this allows for treatment to be rendered within the home environment without the patient traveling for daily care. Speech therapy is a service that can be rendered within the home and can be beneficial when the patient is more comfortable outside of the clinical setting. The patient in question has several disorders that require ongoing care. She was not considered homebound and was thought to have the ability to benefit from outpatient services. Records provided for the review noted that the patient was oriented to person, place, time, and situation. She was able to attend and concentrate on stimuli and was not easily distracted. While she had poor oral motor strength/coordination and impaired chewing to include impaired sensory regulation, the information submitted for the review did not elaborate on why the patient was unable to attend outpatient therapy to address these issues. As such, the denial of coverage for continued home care services (1 skilled nursing visit and 8 speech therapy visits) was not medically necessary. The prior determination is upheld.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for continued home care services (1 skilled nursing visit and 8 speech therapy visits) is upheld. Medical Necessity is not substantiated.