Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chromosomal disorder (ring chromosome 22), hypotonia, vocal cord paresis, hypoplastic optic nerve, feeding intolerance with dependence on gastrostomy tube feedings, sensory hearing loss, and seizure disorder.
Treatment: Skilled Nursing Care In The Home Up To 56 Hours/Week
The insurer denied the Skilled Nursing Care In The Home Up To 56 Hours/Week.
The denial is overturned. 

The patient is a female child with medical history significant for a chromosomal disorder (ring chromosome 22), hypotonia, vocal cord paresis, hypoplastic optic nerve, feeding intolerance with dependence on gastrostomy tube feedings, sensory hearing loss, and seizure disorder. She has poor airway clearance, requiring frequent suctioning and cough assist therapy. She has episodes of desaturation requiring administration of supplemental oxygen, likely related to breakthrough seizure activity. She was recently diagnosed with dumping syndrome, with profound hypoglycemia requiring blood sugar checks and intervention. She is non-verbal, non-ambulatory, globally developmentally delayed. She is fully dependent upon caregivers for all activities of daily living.

She lives with her parents, both trained caregivers. Her brother is autistic, with potential to be aggressive and violent. Her father is home on disability due to severe chronic back pain. Her mother works full time outside of the home as an aide. 

Skilled nursing needs include gastrostomy tube care and feedings, maintenance of aspiration and reflux precautions, monitoring of pulse oximetry with application of supplemental oxygen as needed, airway clearance with routine and as needed breathing treatments and Vest/cough assist therapy, maintenance of seizure precautions with administration of rescue medication as needed, administration of routine and as needed medications, monitoring of blood sugar with intervention as needed for dumping syndrome and severe hypoglycemia, and assistance/performance of all activities of daily living.

Yes, the proposed treatment of 56 hours a week of skilled nursing care is medically necessary.

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... health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1)

This female child has a number of medical needs as a result of and in addition to her chromosomal abnormality, as detailed above. Of particular concern are her respiratory issues and dumping syndrome with profound hypoglycemia. Both of these present potentially emergent situations round-the-clock. While her parents are both trained layperson caregivers, her father is disabled, and her mother works full time outside of the home. In addition, her brother has medical needs that must also be addressed. It is neither safe nor appropriate to expect the patient's parents to provide the level of care necessary to maintain this child's health and prevent morbidity. The requested skilled nursing services 56 hours weekly are medically necessary, appropriate, and the minimum needed to adequately care for this child.