Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has a complicated medical history significant for coloboma, heart defects, atresia choanae, growth retardation, genital abnormalities and ear abnormalities (CHARGE). The patient also has profound developmental delays, hearing loss, esophageal reflux, eosinophilic esophagitis, sleep apnea, asthma, depression, and agitation. He has undergone multiple surgeries to deal with the comorbid features of CHARGE. These surgeries include placement of a gastrostomy tube (GT), placement of bilateral myringotomy tubes, and retinal repair of the right eye, tonsillectomy and adenoidectomy. Due to his complicated medical history and developmental delays, several durable medical devices are required. These devices include a nebulizer, suction machine, portable and infinity feeding pump, oxygen, pulse oximeter, cane for the blind, hearing aid for his right ear, and a stroller. The patient is on GT per pump for all nutrition, hydration and medications, continuous pulse oximetry while sleeping, sleep apneic episodes noted to require gentle patting on his chest and position changes to help, and albuterol nebulizer treatments. The patient attends a special education program Monday through Friday. A letter from his provider indicates the patient has multiple co-morbidities with high possibility of underlying sleep apnea with hypoventilation for which nocturnal oxygen by blow is provided. This provider reported that the patient was not a good candidate for a sleep study, and he will not tolerate continuous positive airway pressure. At issue in this case is whether the requested 168 hours of home care nursing is medically necessary to treat the patients medical condition. Based on the increasing survival of children with complex conditions, it has become more feasible to provide high-technology interventions at home. Complex care in the home setting includes educational as well as clinical management support. The Centers for Medicare and Medicaid Services (CMS) noted that the overarching goal of home health care is to optimize each childs health and function while minimizing recurrent or prolonged hospitalizations through the provision of comprehensive, family-centered health care rendered in a nurturing home environment. Common indications for private duty nursing include the administration of medications, monitoring oxygen saturations, and enteral feeding. In a recent review on home nursing for children with special needs, the review yielded seven randomized controlled trials with a total of 840 patients. The authors noted that three studies reported a reduction in parental anxiety and improvement in child behaviors, and one study found improved parental coping and family functioning.Home nursing is indicated in this case to monitor vital signs, perform nursing assessments, provide gastrostomy tube care, monitor lungs sounds, perform oral suctioning, assist with range of motion, and monitor for skin breakdown. Overall, the patient meets the criteria for private duty nursing as he requires administration of medications, monitoring oxygen saturations, and enteral feedings. Moreover, although the patients family may be able to meet some of the ongoing needs in the short-term, this is not sustainable. Given the patients developmental delays and ongoing need for oxygen, gastrostomy tube cares, and oral suctioning, the requested 168 hours of home care nursing is medically necessary.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics, neurodevelopmental behavioral pediatrics and genetics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.