Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Feeding difficulties
Treatment: Home care private duty/independent nursing (PDN), code T1003 and licensed practical nurses (LPN)/ licensed vocational nurses (LVN) services, up to 15 minutes for 8 hours per day for 7 days per week
The insurer denied coverage for home care PDN, code T1003 and LPN/ LVN services, up to 15 minutes for 8 hours per day for 7 days per week
The denial is upheld.

Patient is a female child with a past medical history notable for a Right-dysplastic horseshoe kidney status post inadvertent bilateral nephrectomy requiring kidney transplant, chronic constipation, gastroesophageal reflux and feeding difficulties status post gastrostomy (GT) placement. To address her medical needs, she had been receiving skilled nursing services 8 hours per day.

The patient is permitted water and apple juice by mouth. She receives 3-4 GT gravity bolus feeds with Nutren Jr. 195 milliliter (ml)/feed. In addition, she receives an additional 480ml of water over the day usually as 120ml GT boluses x (times) 4 as well as water flushes with medications and before and after feeds. The last documented weight is 16 kilograms. Her standing medications include Orapred daily GT, aspirin daily GT, Valcyte daily GT, Prevacid daily GT, CellCept twice daily (BID) GT, tacrolimus BID GT and Atrovent inhaler BID. In addition, her medications available as needed include Tylenol, simethicone, Miralax, Zofran and topical skin care agents (Zinc oxide). She is ambulatory and potty trained. She lives with her mother (primary caretaker) and father. She is followed by transplant nephrology. She is incontinent of stool and urine.
 
This patient has had a kidney transplant and has residual feeding issues ameliorated by GT delivery of feeds, hydration and medications. According to the records submitted for review her care consists mostly of monitoring her overall condition that has been stable, administration of GT medications twice a day, GT feeds/hydration, monitoring for proper hydration and proper positioning during feeds. All of her care needs can be achieved by a trained family member without the need for skilled nursing. 

For this individual, her chronic condition certainly may have met criteria in the past, but her current documented needs appear stable and within the family's ability to assume all of her care without undue burden or risk to the patient. Specifically, her 3 main issues - potential for dehydration, medication/feeding administration and aspiration risk have been well controlled with routine monitoring and no urgent interventions.
 
Although there were no swallowing studies submitted for review this child seems at minimal risk of aspiration during feeds. The fact that she is permitted liquids by mouth would indicate that her swallowing mechanisms are functional despite oral aversions. Her GT feeds are tolerated well without vomiting or respiratory compromise. She has no reported distention, abdominal pain or residuals. There are no reported recurrent pneumonias, impaired oxygenation or frequent deep suctioning that appears mitigated by appropriate precautions. The overall complexity of her current care plan is such that it is reasonable to expect a well-trained non-medical caretaker to provide all of the current allocated care needs without skilled nursing present.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for home care PDN, code T1003 and LPN/ LVN services, up to 15 minutes for 8 hours per day for 7 days per week is upheld. Medical Necessity is not substantiated.