Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe hypoxic ischemic encephalopathy secondary to preterm birth with placental abruption, mixed quadriparetic cerebral palsy, seizure disorder, swallowing dysfunction and feeding intolerance status post gastrojejunostomy tube placement with failure to thrive, severe laryngomalacia, microcephaly, obstructive sleep apnea, chronic respiratory failure treated with high-flow oxygen at night and during periods of respiratory distress, hearing deficits, and global severe developmental delay. 
Treatment: Private Duty Nursing 24 Hours Per Day 7 Days Per Week. 

The insurer denied the  Private Duty Nursing 24 Hours Per Day 7 Days Per Week. 
The denial is overturned. 

The patient is a male child with complex medical history, including the following: severe hypoxic ischemic encephalopathy secondary to preterm birth with placental abruption, mixed quadriparetic cerebral palsy, seizure disorder, swallowing dysfunction and feeding intolerance status post gastrojejunostomy tube placement with failure to thrive, severe laryngomalacia, microcephaly, obstructive sleep apnea, chronic respiratory failure treated with high-flow oxygen at night and during periods of respiratory distress, hearing deficits, and global severe developmental delay. 

Approximately a year ago, the patient was diagnosed with severe pharyngeal collapse, adenoidal hypertrophy, and congestion, and he underwent adenoidectomy and supraglottoplasty. He subsequently has been hospitalized numerous times in the PICU (pediatric intensive care unit) due to his medical fragility and chronic respiratory failure. He has difficulty with airway clearance, and receives treatments multiple times daily with cough assist (at least every four hours), frequent nasopharyngeal suctioning, and Vest therapy with bronchodilators (every six to eight hours). He receives continuous feedings via his gastrojejunostomy tube for twenty hours daily. He remains a high aspiration risk because of his inability to protect his airway. His seizures are described as frequent, intense, and unpredictable, requiring emergent administration of rescue medication via intranasal or intrarectal route. He has been hospitalized numerous times due to refractory seizures. He has failed multiple medication trials with ever worsening EEG (electroencephalogram) results and abnormal MRI (magnetic resonance imaging). He has non-convulsive seizures as well, with episodes of cyanosis and pooling of secretions. He is considered at high risk for sudden death in epilepsy patients (SUDEP). 

The patient currently has been approved for skilled nursing services 16 hours daily, which his care team does not feel is sufficient due to his fragile state and complicated medical needs. 

The patient's skilled nursing needs are enumerated above, and include medication administration (routine and emergent, breathing treatments, enteral medications, seizure rescue medications), GJ (Gastro-Jejunal) tube care and feedings 20 hours daily, maintenance of aspiration and reflux precautions, frequent suctioning due to inability to protect airway and manage secretions with frequent retching and choking, maintenance of seizure precautions with administration of rescue medications as needed, close monitoring of respiratory status with administration of breathing treatments both routine and as needed as well as airway clearance and frequent suctioning, monitoring of high-flow oxygen during sleep and periods of respiratory distress, maintenance of skin integrity, and range of motion to prevent contractures and skin breakdown. He is fully dependent upon caregivers for all activities of daily living, for airway clearance and airway patency, for nutrition, for safety from seizure. 

Yes, round-the-clock skilled nursing 24 hours daily, 7 days per week, is medically necessary and appropriate for this severely disabled and medically fragile young child.
According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents With Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." (1) Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1) 

This young child is severely disabled and medically fragile as a result of his birth injury and all of the complications that he has since suffered. He has numerous skilled nursing needs as described above. He is at great risk of morbidity and even mortality without continuous skilled monitoring and expert nursing intervention. While it is not unreasonable to expect his parents to participate in his care (particularly activities of daily living like changing, dressing, grooming), it is neither safe nor medically appropriate for his parents even as trained layperson caregivers to independently manage his care for any portion of the day. The requested skilled nursing services 24 hours daily 7 days a week are essential for this child to mitigate risk of morbidity and mortality from his severe and fragile condition. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.