Private Duty Nursing denials: what the review data shows

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: A parent of an enrollee has requested authorization and coverage for private duty nursing services, including 40 hours per week of services with a licensed vocational nurse, 16 hours per week of services with a registered nurse, and one to two visits per certification period of registered nurse supervisory services.Dravet syndrome is a severe encephalopathy characterized by prolonged febrile and afebrile seizures starting some time in or after the first year of life. Prior to onset of seizures, infants are developmentally appropriate. The seizures frequently become treatment-resistant, and patients over time develop cognitive, motor, and behavioral delays. Most cases are caused by a mutation in the sodium channel gene SCN1A, although other genes have also been implicated in cases with similar presentations.

Where the denial was upheld

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;…

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with quadriplegic cerebral palsy. The patient is dependent for all activities of daily living. The patient’s transfers are with the assistance of a Hoyer lift. He is fed and given medication through a gastrostomy tube. From 1/1/19 through 2/15/19, the patient had 23 seizures. The seizures were described as not involving loss of consciousness and the patient was reported as being alert after the seizures. No rescue medications were administered for seizures, and none are listed in the prescribed medication list. There is no report that the patient has had unstable health or emergency room visits. No pressure-related skin issues were noted. The patient has requested reimbursement and coverage for 40 hours per week of private duty nursing that were provided from 1/1/19 forward.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Private Duty Nursingwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.