Chronic Home Ventilation in a 9mo.Submitted by Denise M. Goodman, MD, MS
Denial Type: Medical Necessity Concurrent Hospital Course:This was a 9 mo with complex PMH including trisomy 21, congenital heart disease with palliation (not repair), and need for trach/home invasive ventilation. He also had significant developmental issues. Prognosis was guarded, but it was hoped that if he were able to grow at home he might be able to undergo a second stage cardiac repair. His parents were aware that survival long-term was unlikely but were committed to this plan in hopes of offering him a chance. The commercial payer denied the request to cover private duty nursing (which was a covered benefit in the policy) at home, asserting that this was custodial care and that his mother could provide all care herself. In a peer-to-peer call we explained that published national guidelines stipulate that an awake and able caregiver is present at the bedside 24 hours per day and that home nursing is the recommended form that this takes. The medical director was unfamiliar with these guidelines (see citation) and, in view of them, approved home nursing. Sterni LM, Collaco JM, Baker CD, et al. An official American Thoracic Society clinical practice guideline: pediatric chronic home invasive ventilation. Am J Respir Crit Care Med. 2016;193:e16-e35. Appeal Strategy:When guidelines support your recommendation of medically necessary care, providing them will often compel payers to provide this level of coverage. Be aware that private duty nursing is not always a benefit, and this should be discovered early so that alternatives (such as public coverage) can be secured. |