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202108-140239

2021

Fidelis Care New York

Medicaid

Respiratory System

Home Health Care

Medical necessity

Upheld

Case Summary

Diagnosis: obstructive sleep apnea

Treatment: Private Duty Nursing (PDN) services 12 hours per day, 7 days per week

The insurer is denied coverage for Private Duty Nursing (PDN) services 12 hours per day, 7 days per week.

The denial is upheld.

This female patient has a history of tricuspid regurgitation, obstructive sleep apnea (OSA), down's syndrome, and nocturnal enuresis.

The patient does not need daily mechanical ventilation and there is no tracheostomy. There is no need for daily pulmonary toilet or VEST treatment, obstructive sleep apnea diagnosis does not need private duty nursing. Continuous positive airway pressure (CPAP) is the treatment for OSA and this can be done in a simple way by the caretakers. CPAP care is done by the dedicated Durable Medical Equipment company and they have respiratory therapists to help their clients.
Also, the caretakers should be adept at the custodial and medical needs at this time.
The shift report suggests an almost stable course without any recent respiratory compromise.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the Private Duty Nursing (PDN) services 12 hours per day, 7 days per week is upheld. The medical necessity is not substantiated.

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