Opinion ID: 777312
Heading Depth: 3
Heading Rank: 1

Heading: The Medical Necessity Testimony

Text: 42 Oxford relies on affidavits of two of its Medical Directors who have reviewed the Fay case extensively, Dr. Alan Sokolow and Dr. Arthur Dresdale. Dr. Sokolow, a Medical Director at Oxford since 1995, joined the team supervising Mr. Fay's care in 1996. After reviewing reports by Oxford employees familiar with Mr. Fay's medical condition and the records of the treatment Mr. Fay had received since 1992, Dr. Sokolow stated that the private duty nursing care sought by Mr. Fay is not appropriate for his condition and is accordingly not Medically Necessary. Instead, the medically appropriate care would be that care offered at a Skilled Nursing Facility. Dr. Sokolow identified several reasons for his conclusion that an SNF offered the most appropriate type of care, namely that the staff, physical facilities, and resources available at SNFs are not available through home care. After reviewing the standards outlined in the Plan's Medical Necessary definition, Dr. Sokolow stated that 24 hour a day private duty nursing care[] [is] not `the most appropriate supply or kind of service which can be safely provided to [Mr. Fay].' (quoting Plan Certificate at p. 2, ¶ O(4)). 43 Dr. Dresdale, a Medical Director at Oxford since 1997 and a member of the Grievance Committee that heard the Fays' internal appeal, offered similar bases for his unequivocal opinion that Mr. Fay could safely and more efficiently receive the care he requires in a well-equipped SNF. Like Dr. Sokolow, Dr. Dresdale opined that in-home care could not maintain the levels of staff training and experience, equipment, and other medical resources that an SNF could provide. Recognizing Mr. Fay's total dependence on automatic breathing equipment and the care of others, Dr. Dresdale identified the training and education required for SNF nurses, the availability of emergency treatment facilities and backup systems, and the use of self-sufficient power sources as reasons SNF care would best serve Mr. Fay's medical needs. Based on his review of the available documents on Mr. Fay's condition, including the affidavits of the Fays' experts, and his own conversations with regional experts on chronic ventilator dependent patients, Dr. Dresdale concluded that an SNF was a superior care option. 44 The Fays presented counter-testimony of two physicians. The first, Dr. F. Russell Kellogg, a board-certified specialist in both internal and geriatric medicine and the Medical Director of a home health care agency, has served in both hospitals and nursing homes. After examining Mr. Fay and reviewing Mr. Fay's medical history, Dr. Kellogg concluded that Mr. Fay would not tolerate nursing home placement due to his desire to remain independent, the medical risks to him associated with institutionalization, and his specific care needs. Institutionalization is therefore medically contraindicated in this patient's case as it would be devastating both physically and psychologically. Dr. Kellogg explained that a nursing home would have an insufficient number of skilled nurses to supply the constant one-on-one pulmonary care Mr. Fay required. Additionally, Dr. Kellogg stated that nursing homes would provide inadequate assistance feeding and frequently repositioning Mr. Fay. 45 The Fays' second expert, Dr. Mark F. Sloane, holds a board certification in pulmonary diseases and a special qualification in critical care. He has been Mr. Fay's physician since 1991. He noted that Mr. Fay's condition puts him at substantial risk of the following complications: (1) lung infections ...; (2) `plugging' of his tracheostomy, causing an obstruction of his breathing; (3) decubitis ulcers of the skin ...; and (4) bladder infections. Dr. Sloane concluded that such a high risk of complications requires constant, intensive monitoring and that Mr. Fay is most appropriately and safely cared for at home with 24-hour private-duty nursing. Should such private duty nursing prove unavailable, Dr. Sloane opined that in-hospital management [would be] the next most appropriate and safe level of care for Mr. Fay's condition. Dr. Sloane further stated that an SNF would be unsafe for Mr. Fay because the number of nurses per patient is inadequate and patients are seen less frequently than Mr. Fay would require. 46 The Oxford physicians' detailed explanations of their reasons for concluding that SNF care, not home care, was most appropriate for Mr. Fay indicate that private duty care was not Medically Necessary for Mr. Fay under the terms of the Plan. Despite the Fays' presentation of two qualified experts' opinions to the contrary, this Court cannot find Oxford's determination of medical necessity `without reason, unsupported by substantial evidence or erroneous as a matter of law.' Kinstler, 181 F.3d at 249 (quoting Pagan, 52 F.3d at 442). Oxford's directors provide ample evidence to support their conclusions that full-time, in-home care does not best satisfy the four prongs of the Plan's Medically Necessary test. Although the Fays understandably prefer in-home care, Oxford's conclusion that such care was not Medically Necessary so as to fit within the apparent exception to the Plan's exclusion of private duty nursing was neither arbitrary nor capricious. Thus, the Fays' claim for full-time, in-home care fails both under the Plan's general provisions and under any exception to its exclusion of private duty service.