Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, atrial fibrillation, respiratory failure, pneumonia. 
Treatment: Nursing care in home by an LPN (licensed practice nurse) (S9124), 7 days per week, 24 hours a day (split-shift). 

The insurer denied coverage for nursing care in home by an LPN (S9124), 7 days per week, 24 hours a day (split-shift). 

The denial is overturned. 

This case involves a female who has diagnoses that include hypertension as well as dementia, atrial fibrillation, respiratory failure, pneumonia, and history of a prior stroke. Documentation indicated she has a tracheostomy and is on continuous mechanical ventilation to maintain adequate respiratory function. She also has a gastrostomy tube (GT) for feedings. She is dependent on caregivers for all activities of daily living (ADLs). The documentation indicated she has been recommended to receive 24 hours of licensed practical nursing (LPN) services, split shift. The documentation indicated she does have the equipment and supplies that is needed; however, the family is only available to be backup in case the nurse cancels at the last minute. They cannot care for the patient around-the-clock. The documentation indicated their availability will not provide sufficient care for the patient. The documentation indicated a facility is not a safe option for the patient. 

A letter of medical necessity does indicate her past medical history also includes dementia and being nonverbal is her baseline. She was intubated with a tracheostomy on and transferred to a specialty hospital for further management. She was placed on a weaning protocol and has been able to tolerate a few hours off of the ventilator. She is considered ventilator dependent and requires frequent suctioning as well as wound care, medication administration, toileting, feeding and all other ADLs requiring 24 hours of daily care in the form of 2 12-hour shifts. Additional documentation indicated, noted the patient was comfortable on total pressure (TP) 40% (percent). The plan was to discharge the patient. The documentation indicated she was tolerating her diet and was breathing comfortably. There was evidence of edema, and she was incontinent of stool. The patient did have a bilateral sacral and heel pressure ulcer. She is noncommunicative. 

This patient is an older woman who is now bedbound, incontinent of bowel and bladder, ventilator dependent and requiring tube feeding to maintain her nutritional status. She is unable to complete any of her ADLs and requires total care and supervision 24 hours per day 7 days a week. She qualifies for this care based on all the clinical information provided and she cannot be left alone for any duration of time due to her multiple medical conditions. It is well established that elderly patients with dementia do better in their home familiar surroundings and don't do well when they are institutionalized. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for nursing care in the home by a licensed practical nurse (LPN) (S9124), 7 days per week, 24 hours a day (split-shift) is overturned. Medical necessity is substantiated.