Skilled Nursing Care denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for skilled nursing care of a licensed skilled nurse (HCPCS Codes G0300 and G0299). On review of the available medical records, the skilled nursing care of a licensed skilled nurse was and is medically necessary for treatment of this patient. Specifically, the skilled nursing services will help prevent disability and disease progression given the patient’s elevated risk of aspiration pneumonia due to her medically intractable epilepsy, severe gastroesophageal reflux, neuromuscular respiratory weakness, and inability to protect and clear her airway. She is also at risk of pressure sores as she is unable to reposition herself.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for continued home health services (certified home health aide for 120 hours per month and skilled services by a registered nurse for care planning for two hours per month). Pediatric-aged patients with chronic complex healthcare needs may require continued skilled home nursing. Patients needing skilled nursing care include those that require respiratory assessments and treatment of respiratory distress, monitoring for seizures, and managing gastrostomy feeds. Home nursing care is recommended for children with complex medical problems so that they may remain safely in the home. Some patients may require in-home care that does not require the skill set of a registered nurse.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing care and physical therapy services. Functional impairments due to a cerebral insult, such as a hemorrhagic stroke, can be severe to profound. Although functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes (Alawieh, et al.). Notably, most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower to come in the subsequent stages (Kubis).

The representative of a 60-year-old male enrollee has requested skilled nursing care for treatment of the enrollee, who is status post cerebrovascular accident. Findings: The physician reviewer found that the patient continued with right hemiplegia and was not making significant progress with physical therapy and occupational therapy. Per his attending physician, he was alert and appropriate, but demonstrated mild confusion at times. His other medical conditions were stable, and he was not requiring a minimum of two hours of daily nursing by a registered nurse. Per the reference by Goroll and Mulley, the patient was receiving appropriate care post cerebrovascular accident. He was admitted to a rehabilitation facility and received skilled level of care therapies.

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