Skilled Nursing denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for skilled nursing services of a registered nurse in the home health or hospice setting-49 units (G0299).Findings: The physician reviewer found that incidence of childhood cancer in the United States is increased by 0.6%/year. The most common cancer type in childhood is leukemia. Advances in the treatment of childhood cancer have shown an improvement in prognosis in recent years. Therefore, the survivor rate of children with cancer has risen in the past decade. Children with cancer have many problems and symptoms related to disease and treatment. Therefore, planning and implementation of individualized family centered nursing interventions to improve health status in these children are important.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for past in-home nursing services, and future in-home nursing services for up to 16 hours per day. Although dated, the Committee on Children with Disabilities continues to guide treatment decisions in the disabled pediatric population. The guidelines noted that the overarching “goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive…health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities.” Further, children with special needs frequently require equipment at home to allow for safe and effective care.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) skilled services by a registered nurse for management and evaluation of the plan of care (CPT code G0162), 1 unit at 15 minutes each, and (2) direct skilled nursing services of a registered nurse in the home health or hospice setting (CPT code G0299), 3 units at each 15 minutes. Green notes that patients with dementia have unique safety needs due to cognitive and behavioral changes associated with dementia. The author further notes that safety interventions for persons with dementia who remain in their home environment should be considered to mitigate the risks associated with falling, kitchen use and food safety, medication safety, and wandering and personal safety. Despite these measures, constant supervision and caregiver assistance for safety may still be needed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested 16 hours total of skilled nursing services per day for treatment of her medical condition. Findings: The physician reviewer found that the patient has end-stage amyotrophic lateral sclerosis. The patient receives eight hours of skilled nursing services and the request is for an additional eight hours of service. The documentation submitted does not support that the patient has had any new medical complications that would require an additional eight hours per day of skilled nursing services. The Health Plan is currently providing eight hours of care daily by a skilled nurse which is adequate for oversite of plan of care and wound care. The patient requires custodial care 24 hours a day, around the clock. A skilled nurse is able to teach a layperson to care for a feeding tube and to suction via the tracheostomy.

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 Skilled Nursing, then check the rights and deadlines that apply to your plan.