Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Respiratory System.
Treatment:  Home Health Care.

The insurer denied Skilled Shift Nursing in the Home 24 Hours per Day x 7 Days per Week.  The denial was overturned in whole.

The patient is a female child born extremely prematurely at 24 weeks' gestation with a complex medical history including the following:  severe chronic respiratory failure with obstructive sleep apnea status post tracheostomy tube placement with critical airway due to subglottic stenosis and recent tracheal hemorrhage; gastroesophageal reflux disease (GERD) and dysphagia status post gastrostomy tube placement with dependence on gastrostomy feedings for majority of fluids and nutrition; epilepsy with partial complex seizures; spastic diplegia; retinopathy of prematurity; chronic otitis media status post tympanostomy tube placement; recent hospitalization for acute respiratory failure and pneumonia; and global developmental delay.  She is non-verbal and incontinent of bowel and bladder (potty-training).  Pulse oximetry is used during sleep with application of supplemental oxygen as needed via humidified trach collar.  Feedings are administered via pump or bolus followed by water flush.  She lives with her parents, infant brother, grandmother, aunt, and young school-aged cousin.  Prior to the COVID-19 pandemic, she was attending school during the day with skilled nursing.  Skilled nursing needs include tracheostomy tube care, airway clearance and frequent suctioning, monitoring of continuous pulse oximetry with application of supplemental oxygen as needed, monitoring for decannulation due to critical airway and risk for hemorrhage, gastrostomy tube care, intermittent bolus or pump feedings with initiation of oral feedings as recommended, maintenance of aspiration and reflux precautions, maintenance of seizure precautions with administration of emergency medications as needed, administration of enteral and respiratory medications routine and as needed, maintenance of skin integrity, and assistance with all activities of daily living.  The health plan's determination is overturned.  The requested health service/treatment of Skilled Shift Nursing in the Home 24 Hours per Day x 7 Days per Week is medically necessary for this patient.  This young child has a number of medical problems as a result of and in addition to her extreme prematurity as detailed above.  Most concerning is her severe chronic lung disease and her critical airway.  As a result, she has a number of round-the-clock skilled nursing needs.  She must be monitored continuously for respiratory distress, airway obstruction, and tracheostomy tube dislodgement.  Her critical airway, a combination of subglottic stenosis and history of tracheal hemorrhage, should not be managed independently by layperson caregivers because of the risk of recurrent hemorrhage and/or inability to replace the trach tube should it become dislodged.  Further, she has a history of seizures and must be monitored for prolonged seizure activity with the need for emergency medication administration, and she has GERD and dysphagia with poor airway clearance, which place her at significant risk for aspiration with resultant pneumonia.  The complexity of this child's medical problems, fragility of her overall clinical state, and critical nature of her airway necessitate round-the-clock skilled nursing services to maintain health and safety.  To provide less than 24 hours per day of nursing services 7 days per week would place her at significant risk of morbidity and even mortality.