Kristen, a 19-year-old woman, has lived with extremely rare and complex medical conditions all of her life. She depends on a home ventilator machine to get oxygen into her lungs. She also relies on a gastrostomy tube (G-tube), a tube inserted through the abdomen, to deliver all of her nutrition and life-sustaining medications directly to her stomach.
Kristen lives at home with her mother, who is not a licensed nurse but she has learned and personally managed all of Kristen’s skilled nursing needs for all of Kristen's life. Remarkably, Kristen had never received in-home skilled nursing care in the past; her mother performed the respiratory assessments and monitored her home ventilator, performed all medication and feeding administrations, and tended to each and every one of Kristen's care needs. For 19 years, she alone provided Kristen with the medical and personal care (e.g., grooming, bathing) she needed to preserve her dignity and maintain a good quality of life, at home with her family.
When a workplace accident left Kristen’s mother with substantial physical limitations that worsened as she aged, she realized it was time to seek help with her daughter’s care.
Kristen’s doctor requested six (6) hours per day of in-home skilled nursing, the minimum level of care appropriate for Kristen. Despite this, Kristen’s Medicaid managed care insurance plan denied the request entirely, claiming the level of service was not medically necessary and that Kristen’s mother could continue to care for her as she had done for all her life. Kristen's mother contacted PHLP for help.
We represented Kristen in her appeal challenging the Medicaid insurer’s denial. To prepare the case, we worked with Kristen’s doctors and her mother to strengthen the documentation supporting the need for this care; which was made more difficult by the fact that no formal records were available (e.g. nursing notes) since her mother had been doing this on her own for so long.
But ultimately, PHLP got the insurer’s denial overturned. Her mother was and is extremely appreciative. Now, for the first time in Kristen’s 19 years of life, she receives skilled nursing care at home, lessening the strains on her mother and ensuring that Kristen can continue living safely and happily at home where she wants to be.