Diagnosis: Gardner syndrome, rectal adenocarcinoma
Treatment: Long-Term Custodial Care
The insurer denied Long-Term Custodial Care.
The health plan's determination is upheld.

This is a case review for a male with Gardner syndrome, history of stage IIIB rectal adenocarcinoma status post chemotherapy and radiotherapy, status post proctocolectomy with ostomy, and metastatic disease.

The requested Long Term Custodial Care is not medically necessary for this patient. The patient is stable and appears to function independently. There is no functional assessment provided, but per review of the notes, he is able to ambulate and direct his own ostomy care without difficulty. He does have an ongoing chronic back wound that will need continued management; however, this is not sufficient to meet the criteria for Long Term Custodial Care. This can be effectively managed in the outpatient setting with suitable services, such as home nursing care for dressing changes.

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

The health plan's determination of medical necessity is upheld in whole.