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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with bronchopulmonary dysplasia and congenital malformation of the lung. The patient underwent tracheostomy and gastrostomy procedures with tracheostomy decannulation. In a letter, the provider noted the patient was receiving nebulizer treatments and chest physiotherapy. In a letter, the provider noted the patient had a complex history including prematurity. The provider also noted that the patient had recently contracted influenza and required an increase in nursing care for overnight respiratory monitoring. The patient was noted to be ambulatory with a steady gait. The patient was taking food by mouth and tube feedings without difficulty. The patients tracheostomy stoma was not completely closed and was covered with a gauze dressing. The patient was not ventilator dependent and had oxygen available for use as needed. A granuloma was noted over the patients gastrostomy tube site with an open area. No seizures, agitation, aggressive behavior, or pain were noted. Per the submitted documentation, the Health Plan has approved 268 hours of home healthcare for three months. The patients parent has requested authorization and coverage for an additional 132 hours of home healthcare (400 hours total; every 3 months). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether an additional 132 hours of home healthcare (400 hours total; every 3 months) is medically necessary for the treatment of the patients medical condition. Gay and colleagues reported, Private duty nursing (PDN) may implement the care plan for children with medical complexity (e.g., tracheostomy/ventilator dependency) who otherwise could not live safely at home. PDN services are often provided on an extended basis (e.g., 24 hours per day) for many months or years. Despite the growing use of home healthcare services, little is known about the extent to which they influence hospital resource use in children. In this case, the patient does not have a documented severe neurological mobility impairment, ongoing chronic medical device use, or a recent history of surgery necessitating an increase in nursing hours at home. According to the record, the patient receives good care coordination and chronic care management continuity across settings. The medical evidence does not support the requested services in this clinical setting. Therefore, an additional 132 hours of home healthcare (400 hours total; every 3 months) are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty 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.