Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe bronchopulmonary dysplasia
Treatment: Continued inpatient stay 

The proposed treatment is medically necessary based on the patient's complicated medical condition, his medically fragile state, and the New York State Guidelines (Attachment G: Office of Health Insurance Programs Principles for Medically Fragile Children).  The guidelines state the following: A "medically fragile child" is defined as an individual under 21 years of age who has a chronic debilitating condition or conditions who may or may not be hospitalized who meets the following criteria:
1) Is technologically dependent for life or health sustaining functions;
2) Requires a complex medication regimen or medical interventions to maintain or to improve their health status;
3) Is in need of ongoing assessment or intervention to prevent serious deterioration of their health status or medical complications that place their life, health or development at risk.

"Chronic debilitating conditions include, but are not limited to, bronchopulmonary dysplasia, cerebral palsy, congenital heart disease, microcephaly, pulmonary hypertension, and muscular dystrophy."

This is the case of a boy that was born premature at 23 weeks gestation that is medically fragile due to multiple medical problems.  He is ventilator dependent full time due to severe bronchopulmonary dysplasia with chronic respiratory failure.  He has microcephaly and a history of grade 3 intraventricular hemorrhage at birth.  He had a history of a right hemothorax, seizures, retinopathy of prematurity with vision defects, congenital hearing loss, kidney stones, hydronephrosis, pulmonary hypertension, acute drug withdrawal, and dysautonomia. He has profound developmental delays. His most recent admission to the Hospital was following an acute hospital admission for treatment of a perianal abscess.  He reportedly had four prior admissions to the Hospital due to his medically fragile state.  The discharge plan was for this child to be sent to a skilled nursing facility when medically stable.  Reportedly, the child's family was unwilling and felt that they were unable to care for him.  The clinical notes from the Hospital document that over the time in question, no skilled nursing facility bed became available for this child and he remained in need of 24-hour ventilation, skilled nursing care, gastrostomy feeding, multiple medications, and habilitative services.

The patient in this case meets the definition of a medically fragile child.  He is diagnosed with bronchopulmonary dysplasia, microcephaly, and pulmonary hypertension.  He likely has an additional diagnosis of cerebral palsy based on his medical history and description of his neuromuscular examination.  He could not be safely discharged to a home setting with his complex medical needs.  A skilled nursing facility level of care was necessary for him but the discharge remains prolonged due to the lack of an available bed for him.  In the interim, the child is undergoing ongoing medical treatment to reduce the number of his sedating medications, wean him from the ventilator, and provide habilitative services to optimize his functional development.

The patient in this case requires 24-hour nursing care due to his ventilator dependence and complicated medicine regimen.  His fragile condition requires frequent medical decision making to treat signs and symptoms of dysautonomia that can result in further brain damage if not properly treated.  The patient could not be safely discharged to a lower level of care without the necessary skilled nursing, medical equipment, and safe space for the child to be treated.  The treating hospital clearly documented that the patient was awaiting a bed in an appropriate skilled nursing facility and that no bed had become available.