Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lissencephaly
Treatment: HCPCS (Healthcare Common Procedure Coding System) codes S9123, nursing care in the home, by registered nurse, per hour, and S9124, nursing care in the home; by licensed practical nurse, per hour
The insurer denied coverage for HCPCS codes S9123, nursing care in the home, by registered nurse, per hour, and S9124, nursing care in the home; by licensed practical nurse, per hour
The denial is overturned.
 
The patient is an adult who was diagnosed with Lissencephaly since birth. The patient has difficulty swallowing, psychomotor delays, and seizures. The patient has respiratory failure and is status post tracheostomy and is ventilator dependent. The patient has a gastrostomy (G) Tube for nutritional support. The patient was receiving 24/7 nursing care for several years until it was recently denied.

As per the documentation submitted by the patient's doctors to establish medical necessity of 24/7 nursing care, they state that patient's condition has deteriorated over the years with multiple hospitalizations in the past.

She has had continuous ventilator support via tracheostomy and has had multiple episodes of Pneumonia in the past. The patient has significant secretions in her respiratory tract which require pulmonary suctioning done almost every 1-2 hours. The patient also uses airway clearance therapies 3-4 times per day to prevent pneumonia and hospitalization. The patient's nurses have been providing this service for several years and due to the excellent care provided, her last hospitalization for pneumonia was several years ago.

The patient also has a seizure disorder and has seizures off and on. She is on an anti-epileptic regimen which has helped to manage her seizures. She requires constant monitoring for the same and needs nursing care to identify any breakthrough seizures so that medications can be administered in a timely fashion to prevent any long-term sequelae. Sometimes the medications have to be given rectally.

Due to her severe psychomotor retardation, she is unable to care for herself. She is unable to move at all. The patient is receiving enteral feeding for her nutrition for 16 hours along with two bolus feeds as well as water boluses 250 milliliters three times daily (ml tid). She has been able to maintain a stable nutritional state as a result of this.

Since the patient is bed ridden, she needs to be turned and positioned every 2 hours to prevent skin breakdown and ulcers. The patient is incontinent of bowel and bladder and needs frequent changing while being on ventilatory support.

The patient also needs constant monitoring to prevent /minimize risk of infections, prevention of pressure ulcers and skin breakdown. The patient also needs timely administration of her medications to prevent seizures and other medical issues. The patient also needs constant monitoring of her secretions and management of the ventilator.

The patient has been receiving 24/7 nursing care at home for many years which has led to her survival and ability to be managed at home with her family. All the chronic conditions this patient has had remained the same or worsened. Reductions of these services will put her at risk of medical complications and hospitalizations. This is the opinion of all her medical providers who have been managing her for a long time. Based on above, she should continue to receive nursing care at home as before. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for HCPCS codes S9123, nursing care in the home, by registered nurse, per hour, and S9124, nursing care in the home; by licensed practical nurse, per hour is substantiated.