Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Central Nervous System/Neuromuscular Disorder/Seizures,
Treatment: Home Health Care/Private Duty Nurse (RN/LPN) 8 hours x 7 days a week- 56 hours per week.
The health plan denied the requested Private Duty Nurse (RN/LPN) 8 hours x 7 days a week- 56 hours per week as not medically necessary. 
The health plan's determination is overturned, in part.

The patient is a boy who has a chromosomal disorder, 1p36 deletion syndrome, and a balanced translocation between chromosomes 13 and 14. He has an intellectual disability, and is non-verbal and non-ambulatory. The patient had infantile spasms and subsequently developed medically intractable epilepsy. According to reports by his treating pulmonologist, the patient can desaturate following a seizure, and supplemental oxygen has been prescribed. He also has difficulty handling secretions, and is at risk of aspiration. He has been prescribed a suction machine. His medications comprise of Albuterol, Cetirizine, Fluticasone, Polyethylene Glycol, Enalapril, Clobazam, Cannabidiol, and Diazepam as a seizure rescue medication.
A note by his pediatric neurologist, describes that the patient has symptomatic focal epilepsy. His last brain magnetic resonance imaging (MRI) showed a possible choroid plexus cyst, right lateral venticulomegaly, and a focus of gray matter heterotopia. The provider's note describes that the patient has "fair" seizure control, with no "big" convulsive seizures over the last few years. He has "Mild myoclonic seizures several times each month." Mother has never used a rescue medication at home.
The patient has been diagnosed with a mild cardiomyopathy. He underwent ligation of patent ductus arteriosus. He has Brown Syndrome, an eye movement disorder. The patient eats pureed food and drinks by mouth. He is dependent for all activities of daily living, and uses diapers.
The patient lives with his parents and two younger siblings. He attends school, and has a 1:1 nurse to accompany him at school and on the bus ride to school, which can take up to an hour. The nurse's responsibilities include seizure management, including the administration of oxygen as needed, suctioning, administration of rescue medication, diapering, transitions and feeding.
At issue in this case is whether home nursing 8 hours per day, 7 days a week, is medically necessary for this patient.

I overturn, in part, the health plan's determination of medical necessity.

The reviewer finds that the requested health service/treatment of Private Duty Nurse (RN/LPN) 8 hours x 7 days a week-56 hours per week is not medically necessary for this patient, but recommends that 8 hours of nursing be provided during weekdays (40 hours per week) so that the nurse can accompany the patient to school.
The reviewer recommends that private duty nursing be provided for 8 hours per day, 5 days per week during weekdays only so that a nurse can accompany the patient on the school bus and during school hours. Nursing care is necessary during this time to address as needed suctioning, and administration of rescue medication and oxygen during seizures.
Medical necessity is not otherwise met for home nursing. The patient eats orally, and is not documented to need frequent suctioning. He does not have a tracheostomy, and does not require intravenous medication. Diapering, feeding and hygiene care are custodial needs which do not require the provision of a private duty nurse.
The American Academy of Pediatrics Section on Home Health Care Guideline for Pediatric Home Health Care, 2nd Edition,[2] Home Nursing is recommended for children with medical needs in Level 1.