Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal Reflux, Mild Asthma

Treatment: PDN (private duty nursing) services with a Registered Nurse or Licensed Practical Nurse, 24 hours per day, 7 days per week for a total of 168 hours per week

The insurer denied coverage for PDN services with a Registered Nurse or Licensed Practical Nurse, 24 hours per day, 7 days per week for a total of 168 hours per week

The denial is upheld.

The patient is a male with a past medical history notable for Rett Syndrome (loss of purposeful hand skills and spoken language, gait abnormalities, and stereotypic hand movements. Other features - growth failure, epilepsy, disorganized breathing pattern, bone mineral deficit and fractures, autonomic nervous system dysfunction, cardiac abnormalities, dystonia, tremor, and sleep disturbances), chronic respiratory failure status post tracheotomy, ventilator dependent, gastroesophageal reflux, mild asthma, seizure disorder, dislocated hip, non-verbal and feeding difficulties status post gastrostomy tube (GT) placement. To address his medical needs, he has been receiving skilled nursing services 24 hours per day supplied by Caring Hands Health Care since. The medical needs offered for justification of the requested services include:

1)     Vitals 1-2 x (times) per shift
2)     Global assessment
3)     Intermittent oxygen saturation assessments
4)     GT care and GT medications, hydration, and feeds
5)     Tracheostomy care, reflux, Aspiration and seizure precautions
6)     Ventilator management
7)      Airway clearance, suctioning and chest physical therapy (PT) as needed
8)     As need nebulizer treatments
9)     Skin integrity, assessment, and care
10)     Orthotics
11)    Transfers, passive range of motion exercises
12)   Management of bladder and bowel incontinence
13)      Assistance with activities of daily living.
 
He takes nothing by mouth. He receives bolus GT feeds with PediaSure Peptide 140 cubic centimeter (cc) over one hour x 5 per day. Each feed is followed by a 90cc water flush, and each medication is followed by a 20cc water flush. He receives three 40 cc water boluses. There is no current weight given. His standing medications include Peridex oral swab twice per day (BID), Probiotic BID GT, Epidiolex BID GT, Miralax every other day GT and Keppra BID GT. In addition, his medications available as needed include Tylenol, Advil, albuterol nebs, saline nebs, Diastat, Claritin, clonazepam, artificial tears and various topical skin care agents (menthol-zinc topical, hydrocortisone topical). He cannot weight bear because of a spica caste. He receives occupational therapy (OT), PT and speech therapy (ST) 3 x per week. He attends school virtually due to Coronavirus Disease (COVID) restrictions. 
In regard to the standard of care for skilled home nursing care within NY - (42 CFR 409.32)

a)	To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel. 

Given the above factors this patient's medical condition and care needs do not meet standards for medically necessity for 24 hours of private duty nursing per day. His chronic medical conditions and chronic care needs appear stable and within the family's ability to participate meriting a reduction in hours of skilled nursing coverage. It appears unlikely that a 2-hour reduction in skilled nursing daily would create overwhelming burden on the family or jeopardize this patient's overall health status. Periodic adjustments in this patient's treatment plan will continue to occur guided by his chronic multidisciplinary treatment team. 

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

The insurer's denial of coverage for private duty nursing (PDN) services with a Registered Nurse or Licensed Practical Nurse, 24 hours per day, 7 days per week; for a total of 168 hours per week is upheld. Medical necessity is not substantiated