Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a male diagnosed with cerebral palsy, hemiplegia, and generalized epilepsy. The provider noted that the patient has episodes of inattentiveness consistent with brief partial seizures. The patient has been treated with Botox injections, Depakene and Trileptal. The patient was treated with Diazepam for seizures lasting over three minutes or more than three seizures in one hour. The patient did not reportedly require rescue diazepam for seizures. The patient was noted to have one to five seizures per week, manifested by staring, with no convulsive activity and immediate return to baseline. The seizures were reported to last between 10 and 30 seconds. The patients parent has requested coverage for hours per month of home shift nursing care. The Health Plan has denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether the requested hours per month of home shift nursing care are medically necessary for treatment of the patients medical condition. The patient has left hemiparesis, generalized epilepsy, a developmental delay and a learning disability. He is independent for activities of daily living and walks with a leg brace, but without assistance. He does not have a tracheostomy or gastrostomy tube requiring continuous feedings, and does not have pressure sores that require dressing changes. Applying the American Academy of Pediatrics guideline for pediatric home care, intermittent skilled level of care can be provided by a trained caregiver for the patient in this clinical setting. Level one medically complex level of care includes ventilator, tracheostomy, recurrent or frequent suctioning, oxygen therapy in connection with apnea monitoring, maintenance of intravenous therapy, nutritional support via continuous nasogastric or gastrostomy tube feeding, or presence of a central intravenous catheter. The patient does not have any of the conditions listed under level one, which would require the provision of a trained nurse. The patient is medically stable. He does not have medical needs requiring skilled nursing care. The patients seizures are brief, and he did not require the administration of rescue medication. This patients level of care needs corresponds with skilled care, which can be provided by a trained caregiver. Overall, the medical evidence does not support the services at issue in this clinical setting. Therefore, hours per month of home shift nursing care is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with a special qualification in child neurology, and subspecialty certification in hospice and palliative medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.