Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dravet syndrome, Seizures

Treatment: Skilled shift nursing in the home, 24 hours daily, 7 days weekly

The insurer denied coverage for the requested skilled shift nursing in the home, 24 hours daily, 7 days weekly.

The denial is upheld.

This is a female child with a history of seizures as well as the Dravet syndrome, developmental delay, hypotonia, and large atrial septal defect. Documentation indicated that the patient had seizures that are frequent and often difficult to stop. The patient used multiple medications to minimize the frequency of seizures and required skilled intervention when these seizures occurred. The patient required injections of medications to stop these seizures, and these injectable medications needed to be drawn manually; an error in dosing is concerning to be fatal. Furthermore, during these seizures, the patient required proper airway management and due to the severity of this disorder, the patient has been recommended to have skilled nursing services. 

According to medical literature, private duty nursing services are considered medically necessary for patients who are confined to the home, the services are being provided under and directed by a treating practitioner's plan of care, and the services being provided require the professional proficiency skills of a registered nurse or licensed practical nurse/ licensed vocational nurse and are not considered custodial in nature. Homebound is considered for patients who, because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence and there exists a normal inability to leave home and leaving the home require a considerable and taxing effort. In addition, the services being provided must be on an intermittent basis, according to the defined treatment plan in order to ensure the safety of the individual and to achieve the medically desired result and evidence that the services are appropriate with regard to standards of good medical practice and not solely for convenience.  

As per the clinical criteria, the medical necessity of private duty nursing services is based on consideration of whether the patient requires the following: continuous, skillful observation and judgment to maintain or improve health status; ongoing and frequent skilled interventions to maintain or improve health status, and delayed skilled intervention is expected to result in at least one of the following: deterioration of a chronic condition, loss of function, imminent risk to health status, and risk of death; technology to sustain life; and determination of medical necessity is based on submitted documentation, which describes the following elements: complexity and intensity of care, stability and predictability of the child's condition, and frequency of the child's need for skilled nursing intervention. 

In this case, while the patient has epilepsy, the documentation does not detail why the patient is in need of any skilled nursing services that could not be provided by a caregiver. The documentation does not indicate that the patient is in need of care that cannot be provided by a trained caregiver. Therefore, given a lack of additional documentation detailing why the patient is in need of the private duty nursing services daily, the requested skilled shift nursing in the home is not considered medically necessary.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the requested skilled shift nursing in the home, 24 hours daily, 7 days weekly is not substantiated. The insurer's denial should be upheld.