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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for skilled nursing services of a registered nurse in the home health or hospice setting-49 units (G0299).Findings:  The physician reviewer found that incidence of childhood cancer in the United States is increased by 0.6%/year. The most common cancer type in childhood is leukemia. Advances in the treatment of childhood cancer have shown an improvement in prognosis in recent years. Therefore, the survivor rate of children with cancer has risen in the past decade. Children with cancer have many problems and symptoms related to disease and treatment. Therefore, planning and implementation of individualized family centered nursing interventions to improve health status in these children are important. Nursing interventions should include monitoring for and preventing of medical complications and providing information about potential problems and care to families to increase the quality of life. Increased incidence of children diagnosed with cancer has led to changes in the treatment and prognosis of the disease as well as in nursing care. It is well-established that home-based nursing services are essential for parents of children with life-limiting diseases who spend an average of nearly nine hours per day managing their childs basic healthcare needs, such as personal hygiene, feeding, administering drugs, and managing symptoms, pain and sleep related problems during the night. Current data shows that the number of medical appliances and the status of single caregivers correlated proportionally with a greater amount of time needed for the childs care. It is important for these families to receive appropriate support with daily care, through the evaluation of individual needs of the child and organization of care models.In this case, the patient has a medically complex disease with many potential complications from the aggressive but lifesaving chemotherapy she is receiving. The patient is at very high risk for life-threatening, life-limiting complications such as bleeding, infections, sepsis, malnutrition, and pain. The patient needs highly complex medical care that should be provided at home, to maintain the patients quality of life adequately and to avoid multiple and costly emergency department or hospital visits or admissions. Current data supports that it is this patients chronic life-limiting disease with its acute needs and high risk for complications that determines the daily burden of care for the parents and caregivers. The requested home health care registered nurse services are a necessary part of this patient's complex medical care and health maintenance. Accordingly, the requested skilled nursing services of a registered nurse in the home health or hospice setting-49 units (G0299) are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, with subspecialty certification in pediatric rehabilitation 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.