Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Phosphoglucomutase-1 deficiency

Treatment: Skilled nursing care in the home (private duty nursing) up to 10 hours/day x 7 days/week

The insurer denied coverage for skilled nursing care in the home (private duty nursing) up to 10 hours/day x 7 days/week.

The denial is upheld. 

This is a male child with a past medical history notable for phosphoglucomutase-1 deficiency, hyperinsulinemia hypoglycemia, hypoxic ischemic encephalopathy, short stature, mild malnutrition, obstructive sleep apnea, Pierre-Robin sequence, cleft palate status post repair, undescended testis, gastroesophageal reflux, liver test elevations, feeding difficulties status post gastrostomy tube placement. To address his medical needs, he has been receiving skilled nursing services 10 hours per day, 7 days per week. The issue for consideration is the medical necessity of private duty nursing 10 hours per day, 7 days per week.

This patient suffers from a number of stable chronic medical conditions without progression or decompensation. According to home nursing notes the care provided is generally a combination of observation and custodial care. It seems that his plan of care has simplified greatly since his earlier years (continuous tube feeds, aspiration risks, home oxygen supplementation, nebulizer treatment/chest physiotherapy) with infrequent interventions and mainly expectant monitoring of a well-functioning infant.
  
In regards to this child's risk of aspiration with feeds, a review of aspiration in infants and children from UpToDate concludes that children with swallowing dysfunction are at risk for pathologic aspiration that may lead to acute or chronic pulmonary compromise and impaired nutritional intake may result in failure to thrive. This child seems at minimal risk of recurrent aspiration given his recent feeding progress with appropriate precautions and positioning with feeds. 
 
This child's family certainly has the ability to manage this patient's medical care needs even on a daily basis. The lack of complexity to his care plan is such that it is reasonable to expect a non-medical family to master all of the care needs without skilled nursing present. As demonstrated by the nursing documentation this child requires essentially custodial services (feeding orally or via gastrostomy, diaper changes, assistance with activities of daily living) and with no acute nursing interventions. The fact that he has not required urgent or emergent medical intervention for his current medical conditions appears unrelated to his current nursing efforts. 
 
Another tool used by insurers to assess the appropriateness of skilled nursing care is the Private Duty Nursing (PDN) Acuity Grid. This tool has been adapted by regulating agencies to estimate skilled nursing needs based on an objective scoring system. A score below 15 would not merit skilled nursing. This patient's score is below this threshold.  
 
Given the above factors this patient's medical condition and care needs do not meet standards for medically necessity for skilled nursing for 10 hours per day, 7 days per week. The family can be trained/re-trained to deal with the skills needed to achieve adequate care given his current needs and clear improvement over time. Periodic adjustments in this patient's treatment plan will continue to occur guided by his chronic multi-disciplinary treatment team. This decision was rendered based on review of the medical records and accepted skilled nursing care needs standard of care.

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

The carrier's denial of coverage for skilled nursing care in the home (private duty nursing) up to 10 hours/day x 7 days/week is upheld. The medical necessity is not substantiated.