Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic lung disease, Failure to thrive. 
Treatment: private duty nursing care in the home, codes S9124- 1 hour and S9123- 72 hours.

The insurer denied coverage for private duty nursing care in the home, codes S9124- 1 hour and S9123- 72 hours.
The denial is upheld. 

This patient is a female child who had been diagnosed with periventricular leukomalacia, microcephaly, seizure disorder, cerebral palsy, failure to thrive, reflux, global developmental delay, patent foramen ovale, and chronic lung disease. The provider's letter noted that due to the patient's chronic lung disease, the patient is susceptible to viral and bacterial infections placing her at high risk of prolonged illnesses, the need for supplemental oxygen and subsequent hospitalization. In the past, the patient was admitted to the hospital for seizures and a viral illness. The patient was placed on continuous positive airway pressure (CPAP) during the hospital course. It was noted that the patient requires close monitoring for complex medical conditions such as medication administration, respiratory treatments, and seizure precautions. An appeal letter noted that the patient was incontinent and would frequently stop breathing and also aspirate. The patient was non-ambulatory and nonverbal and therefore was unable to express her wants and needs. The patient had difficulty with feedings and was on seizure, safety, aspiration, and choking precautions. The patient required her oxygen levels to be monitored via pulse oximeter while she sleeps requiring oral suctioning for excessive secretions.

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 nurse (RN) or licensed practical nurse (LPN)/licensed vocational nurse (LVN) 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. 

In this case, the patient is currently confined to the home and the services would be considered custodial in nature. The private duty nursing tool accessed in the Milliman Care Guidelines revealed that based on the patient's diagnoses of periventricular leukomalacia, microcephaly, seizure disorder, cerebral palsy, failure to thrive, reflux, global developmental delay, patent foramen ovale, and chronic lung disease, the patient does need medications and monitoring that can be provided by a caregiver. The ability to feed this patient and monitor the pulse oximetry can be done by a trained caregiver. The documentation does not detail why the patient is in need of 12 hours of skilled nursing services. The documentation does not indicate that the patient is in need of care that cannot be provided by a trained caregiver.  

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

The carrier's denial of coverage for private duty nursing care in the home, codes S9124- 1 hour and S9123- 72 hours should be upheld. The medical necessity is not substantiated.