Appeal type: Medical necessity
Decision: Overturned

Diagnosis: C1 Complete Tetraplegia.
Treatment: 168 hours private duty nursing LPN.
The insurer denied 168 hours private duty nursing LPN.
The determination is overturned.

The patient has a past medical history of Crohn's disease who sustained a fall while skiing and required multiple rounds of cardiopulmonary resuscitation with transfer to tertiary hospital. The patient was found to have multiple cervical spinal fractures, an epidural hemorrhage, bilateral pneumothorax, status post bilateral chest tubes, and possible right vertebral dissection. The patient was hospitalized with complications of ventilator associated pneumonia, had a tracheostomy, gastrojejunostomy tube and was subsequently transferred to rehabilitation for cervical (C) 1 tetraplegia. The patient was discharged from rehabilitation to the community with temporary residence at a facility while her home was being renovated.
The patient's physical medicine and rehabilitation provider provided a letter noting the patient was under his care for the residual effects of a traumatic spinal cord injury. The letter noted, as a result of this injury, the patient had a group of impairments best described as C1 complete tetraplegia. The letter also stated that these combined impairments dictated that upon discharge from acute rehabilitation hospital the patient would be 24 hours/day, 7 days/week of nursing level of care to ensure that she would not suffer serious medical complications of her condition. In addition, the letter outlined that the patient breathed using a diaphragmatic pacemaker and without this, she would suffer complete respiratory failure. The pacemaker device was battery powered with an external controller noting while the pacemaker is operational, it provided adequate respiration but should it fail, the patient would cease breathing, and would require immediate attachment to mechanical ventilator via her tracheostomy or resuscitation via an Ambu bag. The provider also noted that the patient required multiple preventative respiratory treatments including deep tracheal suctioning, application of a Cough Assist device, administration of inhaled medications, chest percussion and vibration. The provider's letter also stated the patient had orthostatic hypotension and autonomic dysreflexia with the potential for syncope and the patient was treated with an abdominal binder. The provider noted autonomic dysreflexia can cause acute elevation of blood pressure, with or without bradycardia, to potentially dangerous levels and if untreated may result in death, stroke, intracerebral hemorrhage, or seizure. The physician noted both of these conditions would require rapid assessment with intervention to avoid serious morbidity. This provider also noted that the patient had urinary retention and incontinence and her bladder and kidneys were protected with a suprapubic cystostomy which required changing every month with regular evaluation of patency to avoid clogging, severe urinary tract infection (UTI), kidney, and bladder stones. The provider noted intervention to either unclog or change the catheter was required in a very timely manner as to prevent illness/infection/autonomic dysreflexia. In addition, the provider noted the patient was incontinent of bowel and required a bowel regimen including digital stimulation, stool evacuation, and suppository insertion. The provider noted bowel impaction was a second most common cause of autonomic dysreflexia and the patient would require rapid assessment of rectal vault and disimpaction of stool with medication administration. The provider also noted the patient was insensate below C 2 dermatome and was at extreme risk for pressure ulceration at multiple bony prominences and required multiple inspections per day. Lastly, the provider stated the patient required round-the-clock, daily skilled nursing based on her medical and total care needs as well as her extreme potential for unpredictable changes in her medical condition from stable to unstable.
The patient had a home assessment by the insurer to determine care needs. The assessment also noted the patient had medical supplies including tracheostomy equipment, incontinence supplies, suprapubic catheter supplies, suctioning supplies, oxygen (O2) tank, backup ventilator, cough assist machine, nebulizer, and aflo vest. The patient's discharge summary noted the patient was medically cleared for discharge to home with home care and around-the-clock nursing services. The patient had a telemedicine visit with her physical medicine and rehabilitation specialist who noted the patient had had a fever that morning, that he would review letters of medical necessity for home care coverage, and the patient required a portable, battery-operated suction machine for use in the community. The patient's medical provider provided Department of Health (DOH) form 4359 noting the patient's condition was expected to be permanent and goal was to avoid medical complications and maximize independence in the patient's environment and community. The patient had a home-based assessment by the insurer noting the patient required total assistance with the tasks of ordinary housework, stairs, shopping, equipment management, bathing thing, person to hygiene, dressing upper/lower body, toilet use, bed mobility, and eating while maximum assistance with tasks of meal preparation, managing finances, managing medication, and transportation. The patient was assessed at extensive assistance with tasks of phone use and locomotion. Notes from the assessment stated the patient was transferred via Hoyer and could control a power wheelchair with sip and puff controls. Notes also stated the patient was assisted with suctioning and with Cough Assist and was turned and repositioned every 2 hours. The task based assessment tool assessed an average of 5.32 hours/day of needed assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The insurer provided an initial adverse determination denial notice denying the request to increase private duty nursing 168 hours/week and approving private duty nursing 70 hours/week. The denial stated the patient did not meet criteria as the information provided stated the patient was not on a life support machine, did not require oxygen from a machine to help her breathe, did not require food and medicine through a tube in her stomach, did not take part in any rehabilitation program or therapies for more than 3 hours/day requiring nursing support, did not require medications on a frequent basis being every 2 hours or more and was approved for 70 hours/week of consumer directed personal program (CDPAP) services.
The patient was seen by the physical medicine and rehabilitation provider  with an office note stating the patient had increased dysreflexia symptoms which were attributed to a clogged urinary catheter with noted facial flushing, chills, and pulsations. The notes also stated the patient was attending occupational therapy (OT) and physical therapy (PT), was started on Prolia, was started on iron, was provided a new abdominal binder, had Cough Assist orders adjusted, and noted he had advocated with by Fidelis for increased hours of nursing care. The patient appealed the denial decision. The patient's physical medicine and rehabilitation provider wrote a letter stating the patient required around-the-clock, daily skilled nursing based on her medical and total care needs as well as her extreme potential for unpredictable changes in her medical condition from stable to unstable. The provider stated the totality of the care the patient received, and the need for problem-solving and intervention, is far beyond the ability and training of a home health aide and as such a skilled nursing care was indeed a medical necessity. The provider also noted the patient had multiple daily medical interventions that occurred throughout the course of each day and could not be scheduled. The insurer had an external physical medicine and rehabilitation provider review the patient's case noting 70 hours/week of private duty nursing were reasonable to meet the medical needs of the patient and were medically necessary. The insurer provided final adverse determination denial notice denying request to increase coverage for private duty nursing, licensed practical nurse (LPN), from 70 hours/week to 168 hours/week. The insurer cited criteria from Milliman care guideline and criteria from the New York State Medicaid program private duty nursing policy guidelines.

Yes, the services are medically necessary.
According to the New York Department of Health private duty nursing policy, private duty nursing services are nursing services for patients who require more individual and continuous skilled nursing care than is available from a certified home health agency. The manual also stated private duty nursing services are not warranted for nonskilled tasks such as, but not limited to, turning and positioning, ambulation, transferring, bathing, toileting, oral feeding, dressing, and household chores. The policy also stated the intention of private duty nursing services is to support, not replace, the skilled care provided to a member by parents, family, and other responsible caregivers. In addition, the policy stated backup caregivers would need to be identified for use when he nurses not available. The policy states services must be rendered only under the direction of a physician as a part of a comprehensive program of care and approval of services required documentation from the ordering provider of all skilled nursing tasks necessary for care of the patient. The patient's medical provider outlined in detail in two letters the patient's skilled nursing needs which included scheduled and as needed medication orders, nebulizer treatments, tracheostomy care, suctioning, monitoring of diaphragm pacemaker, chest therapy, suprapubic catheter care, and bowel regimen. The provider also documented the patient had extreme potential for unpredictable changes in her medical condition from stable to unstable and the patient's totality of care and the need for problem solving and intervention would be far beyond the ability and training of a home health aide and documented skilled nursing care was medically necessary. Per Milliman care guidelines indication for private duty nursing was indicated when skilled care for frequent nurse clinical monitoring exceeded the scope of intermittent home care or custodial care, post-acute inpatient skilled care was not appropriate, patient's care needs could be managed safely in a home setting, patient had a caregiver support network, patient was safe at home, primary care provider was willing and able to follow the patient during private duty nursing course of service and the patient's total acuity score was 15 points or higher based on a private duty nursing (PDN) acuity tool calculator and 1 or more of the following categories such as bowel and bladder management, case management, patient management, mobility or rehabilitation management, skin and wound management, or respiratory management. As outlined in detail by the patient's physical medicine and rehab provider in his 2 letters to the insurer the patient meets criteria/indications for admission for private duty nursing. In addition, the patient met conditions for continued private duty nursing care as defined by the Milliman care guidelines as the patient's condition, as outlined in the patient's physical and medicine rehabilitation providers letter, the patient continued to required skilled nurse clinical monitoring and decision making, there was ongoing clinical management needed with licensed nurse, the patient's caregiver had more to learn and demonstrated ability to carry out self management, patient was progressing toward healthcare goals, patient was safe at home, and patient's care needs cannot be met in custodial care.