Appeal WON

It is still amazing what insurance finds to be custodial care....the end of July we got a denial letter for continuation of nursing services and as of September 22nd no more nursing.  The reason for denial, custodial care, to be exact it said that “Private Duty Nursing Service means Skilled Nursing Service provided on a one-to-one basis by an actively practicing registered nurse or licensed practical nurse. Private Duty Nursing is shift nursing at 8 hours or greater per day and does not include nursing care of less than 8 hours per day. Private Duty Nursing Service does not include Custodial Care Service. The use of skilled or private nurses to assist in daily living activities, routine supportive care or to provide services for the convenience of the patient and/or his family members is also an exclusion. Custodial Care Services means any service primarily for personal comfort or convenience that provides general maintenance, preventive, and/or protective care without any clinical likelihood of improvement of your condition. Custodial Care Services also means those services which do not require the technical skills, professional training and clinical assessment ability of medical and/or nursing personnel in order to be safely and effectively performed. These services assist with routine medical needs and are to assist with activities of daily living. Custodial Care Services also means providing care on a continuous Inpatient or Outpatient basis without any clinical improvement by you. Respite Care services means those services provided at home or in a facility to temporarily relieve the family or other caregivers (non-professional personnel) that usually provide or are able to provide such services for you. Custodial and respite Care are benefit exclusions based on the information provided, the members care would be defined as custodial, and respite care, since the caregivers can and have been trained to provide the care, and the request of the care appears to be for the relief of the caregivers. Skilled nursing visits are in benefit and are available on an intermittent basis for clinical assessment of the member, caregiver teaching and/or training. The skilled nursing visits can be provided, if requested by the treating physician, are determined to be medically necessary, and do not exceed any benefit limit. 

This was shocking to us, with everything Ian has going on medical for them to actual say it was for our respite or  convenience, as well as not seeing improvement, really ....so I set out to write an appeal. It was frustrating to me that I actually had to find the time to write one but I knew I had no choice.  Yes, Ian had Medicaid and they would have picked up the nursing services. However, in order for them to take over an appeal had to be done. I wanted to win the appeal as Medicaid should not have to pay, our primary insurance should be paying. Well the doctor who reviewed the appeal agreed and over turned the denial....nursing services approved until August 2014.