This morning was our first level appeal for continued skilled nursing. I attended via teleconference. When you go through an appeal with Medicaid, they actually use the appeals department at Blue Cross.
We submitted two letters of Medical Necessity, two weeks of nurse’s notes, Corey’s plan of care and several summaries of care from assorted doctors; such as the seizure specialist and primary care physician. I am allowed an opportunity to advocate on Corey’s behalf with a 10-15 minute statement pleading why we believe our appeal should be approved.
The panel was introduced prior to taking my statement. The Medical Director and two members of Blue Cross were present along with the impartial moderator. I was given my start time.
I prepared 5 key points which included details as to why we need skilled nursing and not a home health aide.
1. VP shunt – a skilled nurse is trained to recognize the signs/symptoms of a blocked shunt which requires prompt medical treatment. Corey has weekly migraines and headaches. A skilled nurse can assess the difference and administer “as needed” medication to relieve her pain.
2. Seizure – Corey’s medication is 60% effective. She does have break through seizures requiring Oxygen and Diastat (a controlled substance) to be administered as part of seizure precaution/protocol. In addition, she will be taking an ambulatory EEG due to increased focal seizures. A skilled nurse is trained to recognize the signs of seizures and check vital signs to execute protocol.
3. Aspiration – Corey’s feeding tube was removed, however, she has severe reflux requiring 80mg of Nexium. She chokes daily when she eats and drinks as she is still developing the muscles required for swallowing her food/drink. During the night, she will experience the same regurgitation; however, she does not wake herself up. She can not sit up independently and if she falls off her pillow and/or should accidently roll over, she can not adjust herself therefore is at risk for aspiration.
4. Behavior and Memory – Corey’s injury has left her with severe memory loss. She is unaware of the time, day, current year and/or season of the year. Her behavior can be combative and volatile. Her behavior management plan can only be carried out by a higher level of skilled nursing which may also require administering additional medication assessed by the nurse.
5. We are appealing a home health aide and 40 hours of coverage for several reasons; A home health aide can not administer any medications, especially the “as needed” medications, cannot turn the dial for oxygen nor administer diastat for a breakthrough seizure, cannot use the suction machine to assist with the risk of aspiration either during the day or through the evening and is not educated or trained to properly assess the management of a VP shunt or carry out seizure protocol.
The Medical Director thanked me for my input and stated she would take these points into consideration during their review. She asked two questions; when was the last time Diastat was administered and when the last time suction was was needed. I reiterated that Corey may not be having seizures daily or weekly, she may have moments of choking that don’t require suctioning but these “dates” are not indicative of her daily need for skilled nursing. I continued with the letter of medical necessity that Dr. Long, the Director of the Brain Injury Unit at Bryn Mawr, has clearly emphasized that Corey’s current level of care requires skilled nursing for round the clock care and supervision. I also pointed out the documentation from the home health agency was not accurate as we do not have consistent staffing. At the moment we have two overnight and two day shifts covered, I am “on” 5 nights and 5 days. (There was no acknowledgement to this rebuttal)
The panel thanked me for my participation. Just before the call disconnected, I asked the Medical Director one last question, “Could you please tell me your medical back round”?
Her response, “I am a certified OBGYN”
The panel made their determination by the end of the business day. I will receive a letter with their decision within the next 5 days. If we disagree with the outcome, we can file a second level appeal.
The rest of the day was more productive! I attended a BIA-NJ webinar on Self Advocacy. The information gained from this class will continue to assist us in the development of our Advocacy Company, 2nd Call Advocacy Group, as well as assisting families that call into the BIA-PA resource line.
Corey’s ultrasound went well. She participated and the pictures were clear. We are trying to determine if Corey’s chronic urgency and frequency is a clinical issue or a neurological issue related to her short term memory. We will get the results next week. Depending on the outcome we may seek an opinion from an Urologist.
We closed the day with an IEP meeting with the school district. The team is working cohesively with Bryn Mawr. The team’s primary focus will continue to physically strengthen muscles, cognitively strengthen memory and discovering what connections are still developing.
Quite a day…and some of you think we sit home eating bon bon’s!
Finally, I’m excited to present the movie filmed by Bryn Mawr of Corey walking on the Lokomat. This short clip will air on their website to promote the possibilities that rehabilitation can offer. We hope you enjoy watching Corey walk on this amazing machine, xoxo