Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Classical congenital adrenal hyperplasia
Treatment: Consumer Directed Personal Care Assistance
The insurer denied the Consumer Directed Personal Care Assistance
The denial is overturned.

The patient is a male infant with medical history significant for classical congenital adrenal hyperplasia hospitalized for three weeks in the NICU (neonatal intensive care unit) following life-threatening adrenal crisis associated with electrolyte abnormalities. He is currently maintained on hydrocortisone, salt supplementation, and fludrocortisone. He is breastfed. His mother is the primary and sole caregiver. His father is not living in the home, and there are no other adults involved in his care. Based on information in the Comprehensive Pediatric 0-3 Assessment Report, his mother is not working outside of the home or going to school outside of the home. According to the letter of medical necessity, he remains at risk for life-threatening events, including adrenal crises with any febrile illness or poor feeding, requiring caregiver knowledge and experience in warning symptoms.

The patient's skilled nursing needs include medication administration and constant monitoring for signs and symptoms of decompensation (e.g., from acute febrile illness, poor feeding) that could result in adrenal crisis.

The request for consumer directed personal care assistance was denied based on the results of the assessment showing that the infant was functioning in an age-appropriate manner, medically stable, with an able caregiver competent in completing appropriate daily tasks for the infant.

Yes, the Consumer Directed Personal Care Assistance 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, 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 young male infant is medically complex, requiring more care and monitoring than a typical infant his age because of his diagnosis of classical congenital adrenal hyperplasia and the potential for life-threatening complications. While his mother is able to meet his general needs of feeding and diapering and bathing and dressing and even medication administration, she also requires some time to perform household duties and take care of activities outside of the home (e.g., personal doctor appointments, shopping, dentist appointments, etc). Usual daycare and babysitting caregivers are not appropriate because they are not trained to recognize impending decompensation and dangerous life-threatening situations. Only skilled nursing personnel are appropriate caregivers when the mother must be away from the home or otherwise occupied. Consumer directed personal care assistance is therefore medically necessary and appropriate in this instance to assist the mother in the care of her medically complex infant son.

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