Appeal type: Medical necessity
Decision: Upheld

The patient was born at 24 weeks' gestation, birth weight 1 pound (lb) 5 ounces (oz), by emergency Cesarean section following a pregnancy complicated by pre-eclampsia, and "placental rupture." Per her pediatrician's letter, the patient has spastic diplegic cerebral palsy, spastic quadriplegic cerebral palsy, unspecified lack of expected normal physiological development in childhood, bronchopulmonary dysplasia, and is fed by a gastrostomy tube. She had a tracheostomy placed, and has a history of postprocedural subglottic stenosis. Per the nursing notes, the tracheostomy has been decannulated and is covered by a Bandaid.
Letters by the patient's mother's physicians describe that the mother has antiphospholipid syndrome, chronic back pain from a previous spinal fusion, and hypertension. They recommended twenty four hour nursing care for the patient. A lawyer's letter notes that father is a firefighter who frequently works 24 hour shifts. He sustained burns to his head and arms in a fire. 
There are multiple nursing reports that describe that the patient requires ambulatory assistance for mobility. She is able to use a stander. It was not documented that she had a Hoyer lift for transfers. Custodial care (repositioning, dressing, diaper changes, application of barrier cream, and application of leg braces) is documented as being performed by the home nurses. Feeds, medications and flushes are administered by gastrostomy tube, (a Mic-key button) including lactulose and simethicone. Albuterol and budesonide nebulizers are administered as needed, with oxygen via facemask as needed.
It is not documented that the patien has seizures. She is not on continuous gastrostomy feeds. Her tracheostomy has been decannulated, with minimal secretions per nursing documentation. According to the lawyer's letter, the patient was in the hospital for an infection in December. Reports from her pediatrician providing further details were not provided.
At issue in this review is whether the requested health service/treatment of skilled private duty nursing care- 24 hours a day, 7 days a week is medically necessary for this patient.
The health plan's determination is upheld.
The requested health service/treatment of skilled private duty nursing care- 24 hours a day, 7 days a week is not medically necessary for this patient. The approved 20 hours of skilled nursing care is medically appropriate. Indications for 24-hour nursing care are not documented. The patient is not reported to have a history of seizures. She is not on total parenteral nutrition or dialysis, and is not on a ventilator. She is not documented to require frequent suctioning. Her tracheostomy has been decannulated. She is not on continuous gastrostomy tube feeds. Although the mother's physicians have stated that she is unable to lift the patient, the family does not appear to be utilizingtransfer assistance, such as a Hoyer lift. While the provision of home nursing care to children with chronic medical needs is important, the patient's medical issues are not sufficiently complex to warrant 24-hour nursing care, per the recommendation of the American Academy of Pediatrics [1].
Her medical needs fall into category 2, requiring intermittent skilled care.
Level 1: Medically Complex:
1)Ventilator dependent
2)Tracheostomy
3)Need for recurrent or frequent suctioning
4)Oxygen therapy in connection with apnea monitoring
5)Maintenance of intravenous therapy including indwelling catheters
6)Nutritional support-continuous nasogastric or gastrostomy tube feeding, central line
Level 2: Intermittent Skilled
1)Aerosol treatment with postural drainage
2)Nutritional support-intermittent nasogastric or gastrostomy tube feeding
3)Dressing changes
4)Daily injection therapy
5)Intravenous therapy-intermittent medication therapy
6)Oral medication therapy
7)Feeding program therapy
8)Monitored diet
Level  3: Continuous Skilled  Monitoring
1)Apnea monitor without oxygenation
2)Seizures