Diagnosis: Cardiac/Circulatory Problems.
Treatment: Home Health Care (180 hours of home health aide services).

The insurer denied 180 hours of home health aide services. The health plan's determination is overturned in whole.

This is the case of a male with medical history of heterotaxy, developmental delay, anomaly of the larynx and epiglottis, atrial septal defect (ASD) with single atrium, anomalous atrioventricular (AV) excitation with 1st degree AV block, advanced bone age, vitamin D deficiency, hoarseness, seasonal allergies, and mild intermittent asthma. He has a history of choking with eating due to his abnormal anatomy.

Per medical documentation provided, home medications include oral iron tablets, acetaminophen liquid as needed, albuterol nebulizer as needed, and loratadine oral tablet as needed. He is on a pureed diet and working on solid food intake. The patient receives speech therapy once weekly, which includes oral motor and swallowing therapies. Per nursing recertification note, the patient is ambulatory independently, able to communicate needs verbally, reads and writes, and is continent of bowel and bladder.

The requested service is 180 hours of home health aide services. Specifically, his physician notes safety issues related to choking concerns. At issue is whether this level of support is medically necessary. Claim was previously denied due to being deemed custodial in nature.

The health plan's determination is overturned in whole.

Yes, the requested service of 180 hours of home health aide services is medically necessary.

This is a patient with developmental delays and physical anomalies that make feeding difficult. He received speech and occupational therapy (OT) services for these deficits and is progressing, yet still requires some dietary modifications and close monitoring during eating.

Based on this child's health diagnoses and condition, HHA services is medically necessary. This child has anatomical differences that make him susceptible to choking episodes. He is on a special consistency diet and is receiving professional therapies to advance the diet to learn to safely chew and swallow solid foods.

The requested service of home health aide 180 hours is considered medically necessary for this patient based on the medical documentation provided.