Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rett syndrome, autism spectrum disorder
Treatment: Private Duty Nursing
The insurer denied the Private Duty Nursing.
The determination is upheld.

The patient has Rett syndrome, autism spectrum disorder, cognitive impairment, and medically intractable epilepsy. She is unable to care for herself, and requires oral feeding by a caregiver. She is at risk of aspiration and has had two hospitalizations for pneumonia over the past few years. She is prescribed rectal Diastat for prolonged seizures. Her medications comprise Trileptal, Lamictal, Lexapro, melatonin, Klonopin, glycolax and norethindrone. Her provider recommended skilled nursing (Private Duty Nursing) for 8 hours daily.
Extensive nursing records were reviewed. There were two clearly documented seizures involving 20 seconds of rapid movements of all limbs, with the seizure lasting less than 1 minute. No Diastat was given.  Several episodes of twitching of the arms were noted, but these are not specifically described as being seizures. The nursing notes report that massage was given for these events. Two doses of as needed Klonopin were given orally for episodes of agitation.
The care given by the nurse is described as involving bathing, diaper changes, transfers, administration of oral medications and enemas, taking the patient for walks, feeding her by hand, and light housekeeping.
At issue in this review is whether the requested health service/treatment of private duty nursing is medically necessary for this patient.

The requested health service/treatment of Private Duty Nursing is not medically necessary for this patient.
The care being provided to the patient by the private duty nursing service is custodial. Descriptions of the tasks performed by nurses include bathing, diaper changes, transfers, administration of oral medications and enemas, taking the patient for walks, feeding her by hand, and light housekeeping. She has infrequent uncontrolled brief seizures. There is no documentation that rescue medications for prolonged seizures were required in several months of nursing care.
According to the American Academy of Pediatrics Section on Home Health Care. Guideline for pediatric home health care, 2nd edition [1], and Home nursing is recommended for children with medical needs in Level 1. The patient does not have any of these medical needs. Similar requirements for provision of private duty nursing are described by Peacock et al [2].
Level 1: Medically Complex:
1)  Ventilator dependent
2)  Tracheostomy
3)  Need for recurrent or frequent suctioning
4)  Oxygen therapy in connection with apnea monitoring
5)  Maintenance of intravenous therapy including indwelling catheters
6)  Nutritional support-continuous nasogastric or gastrostomy tube feeding, central line
Level 2: Intermittent Skilled
1)  Aerosol treatment with postural drainage
2)  Nutritional support-intermittent nasogastric or gastrostomy tube feeding
3)  Dressing changes
4)  Daily injection therapy
5)  Intravenous therapy-intermittent medication therapy
6)  Oral medication therapy
7)  Feeding program therapy
8)  Monitored diet
Level 3: Continuous Skilled Monitoring
1)  Apnea monitor without oxygenation
2)  Seizures
 
Therefore, the requested services are not medically necessary.