Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for 112 hours per week (16 hours per day) of nursing services. Myasthenia gravis causes weakness in the skeletal muscles. This condition may affect breathing, chewing and movement of extremities. Individuals with this condition may experience weakness and fatigue at the end of the day or after prolonged activity. This fatigue can lead to increased risk of complications, including aspiration of secretions and poor airway management. Patients with this condition often require close supervision and frequent tracheal suctioning. Additionally, patients with myasthenia gravis may require more assistance for self-care activities towards the end of the day and evening hours.This patients provider reports a history of myasthenia gravis status post tracheostomy for chronic respiratory failure. As noted in the medical literature, patients with neuromuscular disease have complex medical needs that oftentimes require home health nursing services. Interventions include monitoring for and preventing problems to increase the patients quality of life. Home-based nursing services are essential for caregivers of patients who spend an average of nine hours per day managing a patients basic healthcare needs. In this case, the patient remains at high risk for medical complications including aspiration, infections, and sepsis. He requires highly complex care that should be provided in the home setting to maintain his quality of life and avoid recurrent hospital visits or admissions. According to the home healthcare records, a nurse is needed to provide full pulmonary care each night including checking the ventilator settings, suctioning, and monitoring of oxygen saturation. The nurse also cleans the tracheostomy and gastrostomy tube stomas, provides all required medications, and monitors the environment for safety issues. This patient requires help with transfers when he is weak in order to prevent falls. It should be noted this patient also has autism, and his provider has indicated this results in a very diminished ability to judge his need for self-care and safety. Furthermore, myasthenia gravis is associated with waxing and waning of fatigue depending on energy expenditures. This makes it difficult to estimate when the care may be necessary, and thus skilled nurse supervision is frequently required for safety purposes. The patient would be placed in risk without the requested nursing case, including significant risk as it relates to breathing. Given these findings, the 112 hours per week (16 hours per day) of nursing services (CPT S9123 and S9124) were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.