Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic respiratory failure, vent dependent, recurrent aspiration, CAD (coronary artery disease), CHF (congestive heart failure), hypertension, diabetes, right AKA (above-knee amputation), Parkinson's disease and anemia. 

Treatment: Increase Licensed Practice Nurse (LPN) services to 12 hours/day, 7 days/week x 2 (split shift), total 168 hours/week. 

The insurer denied the Increase Licensed Practice Nurse (LPN) services to 12 hours/day, 7 days/week x 2 (split shift), total 168 hours/week. 

The denial is upheld. 

The patient is a male. His conditions include chronic respiratory failure, vent dependent, recurrent aspiration, CAD (coronary artery disease), CHF (congestive heart failure), hypertension, diabetes, right AKA (above-knee amputation), Parkinson's disease and anemia. He had a recent admission with septic shock and aspiration pneumonia.  This is appeal for denial of an increase Licensed Practice Nurse (LPN) services to 12 hours/day, 7 days/week x 2 (split shift), total 168 hours/week.  The Health plan approved LPN (Licensed Practice Nurse) 12 hours day, 7 days/week, total 84 hours/week and PCA (personal care assistance) 12 hours/day, 7 days/week, total 84 hours/week. 

Skilled visit notes show the patient's vital signs are stable. The notes include G-tube feedings, diaper changes, clean decubitus wounds, turn every two hours, administer nebulizer, and suction trach.  UAS (upper airway stimulation) evaluation completed shows severely impaired cognition and functional status is total dependence.  The patient is bedbound and transferred using a Hoyer lift.  He has a urinary catheter, and he is incontinent of bowel. 

A statement from the patient's caseworker notes the patient was discharged from LTAC (long term acute care) with a ventilator.  The patient has a trach and PEG (percutaneous endoscopic gastrostomy).  They further note the patient needs suctioning, wound care, medication administration, toileting, feeding and assistance with other ADLs (activities of daily living). They are requesting a nurse 24 hours a day.  A statement from the patient's doctor requests 24 hours, split shift LPN (Licensed Practice Nurse), because the patient is ventilator-dependent. 

No, the Increase in Licensed Practice Nurse (LPN) services to 12 hours/day, 7 days/week x 2 (split shift), total 168 hours/week is not medically necessary. 

This patient has multiple chronic conditions, including vent-dependent respiratory failure.  He was admitted with septic shock and aspiration pneumonia.  He was discharged from LTAC (long-term acute care) on a vent with a trach and PEG (percutaneous endoscopic gastrostomy).  He is bedbound and totally dependent.  This is appeal for denial of an increase Licensed Practice Nurse (LPN) services to 12 hours/day, 7 days/week x 2 (split shift), total 168 hours/week.  The Health plan approved LPN (Licensed Practice Nurse) 12 hours day, 7 days/week, total 84 hours/week and PCA (personal care assistance) 12 hours/day, 7 days/week, total 84 hours/week. 

The appeal letters are requesting 24-hour LPN (Licensed Practice Nurse), because the patient is vent dependent and needs 24 hour care.  However, LPNs (Licensed Practice Nurses) are not trained for ventilator management.  The information provided does not support the requested 24 hour LPN (Licensed Practice Nurse) service.  The proposed increase Licensed Practice Nurse (LPN) services to 12 hours/day, 7 days/week x 2 (split shift), total 168 hours/week is not appropriate or medically necessary.