Gracie is a 14-year-old girl with Cerebral Palsy and Epilepsy. She uses a feeding tube for all her nutrition and is non-verbal. Gracie’s grandmother, her only caregiver, called PHLP after Gracie was denied 24 hours a day of in-home skilled nursing care. The requested nursing hours were intended to be used temporarily to care for Gracie while her grandmother recovered from surgery, a process that her grandmother’s doctor said would take at least three weeks, yet Gracie’s health plan did not think the nursing care was medically necessary for the full three-week recovery period; they authorized just 3 days of 24-hour care—not nearly enough to ensure Gracie’s health and wellbeing while her grandmother recovered. Uncertain about what to do and in desperate need of help, Gracie’s grandmother tried to get by without the 24-hour help after the three days. She ended up knocking on neighbors’ doors for assistance with caring for Gracie. That is when Gracie’s grandmother called PHLP.
Due to the urgency of the situation, we immediately began working with Gracie’s home health agency and pediatrician to get the 24-hour care reinstated for the full three weeks. We requested an expedited hearing and contacted the health plan’s legal counsel to discuss the matter. In just a few days, we were able to settle the case without the need for a hearing after the health plan agreed to authorize 24-hour per day nursing care for the remainder of Gracie’s grandmother’s recovery. Our work settling the case allowed Gracie to receive the care she needed and her grandmother the time and assistance she needed to recover from surgery.