Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoxic brain injury
Treatment: Skilled Nursing Care In The Home Up To 24 Hours Per Day 7 Days Per Week (S9123), Pre-service
The insurer denied the skilled nursing care in the home up to 24 hours per day 7 days per week (S9123), pre-service.
The denial is overturned.

The patient is a female infant born at term via emergency cesarean section with severe hypoxic ischemic encephalopathy requiring tracheostomy tube placement with mechanical ventilation and supplemental oxygen as well as feedings via gastrostomy tube. As a result of her hypoxic brain injury, she has minimal spontaneous mobility as well as spasticity of the extremities, contractures of her hands, and temperature instability. She is ventilator dependent due to episodes of apnea. She has no ability to clear her airway and is at risk for aspiration with subsequent pneumonia.

The patient was transferred from the NICU (neonatal intensive care unit) to a pediatric rehabilitation facility, and then to the PICU (pediatric intensive care unit) because of respiratory instability and recurrent apnea. She remains in the PICU (pediatric intensive care unit). Her parents work outside of the home full time to meet family expenses. There are two older siblings.

The patient's skilled nursing needs include tracheostomy care, management of mechanical ventilation, monitoring of continuous pulse oximetry with adjustments in supplemental oxygen as needed, gastrostomy tube care and feedings, maintenance of aspiration and reflux precautions, administration of routine and as needed medications, maintenance of skin integrity with frequent assessment for skin breakdown, and performance of all activities of daily living.

Yes, the skilled nursing care in the home up to 24 hours per day 7 days per week (S9123) are medically necessary and appropriate.

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

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 medically fragile infant has numerous medical problems as a result of her severe global hypoxic injury with subsequent severe hypoxic ischemic encephalopathy. Her skilled needs are detailed above. She basically requires ICU (intensive care unit) level care, with frequent monitoring of airway and respirations, neurologic status, and feeding tolerance. In the absence of round-the-clock (24-7) nursing, this infant would require hospital placement and would lose the loving and caring environment of her home and being with her family. It is neither safe nor appropriate to expect layperson caregivers in this instance to manage all of her needs regardless of the fact that both parents are working full time with other children to raise. This infant needs the skills and expertise of experienced nurses to remain safe in her home environment. The requested skilled nursing hours (24 hours daily 7 days weekly) are medically necessary and appropriate, aw well as essential for this infant to be discharged home.