Home Health Care denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The enrollee’s parent has requested authorization and reimbursement for pediatric day health care and private duty nursing/nursing care at home. The record indicates the enrollee is diagnosed with Koolen de Vries Syndrome after genetic testing was done and revealed KANLS1 mutation. The enrollee had been feeding poorly after delivery and magnetic resonance imaging (MRI) of the brain showed dysplastic corpus callosum. She spent approximately four weeks in the Neonatal Intensive Care Unit prior to discharge home, related to her feeding issues. She subsequently underwent gastrostomy tube placement and takes 40% of nutritional needs by mouth, with the rest being delivered via gastrostomy (G) tube. She has hypotonia, eustachian tube dysfunction, tracheomalacia, reflux, silent aspiration, audio neuropathy and developmental delay.

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.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for the administration in a hospital-based outpatient infusion center setting for authorized Inflectra infusions. The provided clinical documentation does not provide medical reasons to support the medical necessity of subsequent Inflectra infusions in the hospital outpatient facility infusion setting rather than a community-based outpatient facility or home infusion. Inflectra is U.S. Food and Drug Administration (FDA)-approved for induction and maintenance of remission in patients with Crohn's disease. High-quality clinical trials support the use of Inflectra in patients with Crohn's disease. Once initiated, Inflectra should be continued on a maintenance schedule.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for private duty nursing services (CPT G0300 – 4320 units, CPT G0162 – 48 units). At issue in this case is whether the requested private duty nursing services (CPT G0300 – 4320 units, CPT G0162 – 48 units) are medically necessary to treat the patient’s condition for any of the following:• to prevent disease, disability, and other health conditions or their progression;• to prolong life;• to promote physical and mental health and efficiency; or• to correct or ameliorate any physical or behavioral conditions.The submitted documentation does not support that the requested services are medically necessary for any of the following reasons: to prevent disease, disability, and other health conditions or their progression; to prolong life;…

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving home health care, then check the rights and deadlines that apply to your plan.