At just one month old, Millie was diagnosed with a feeding intolerance that led her to become dependent on a tube that carries food and medicine to her stomach through her nose. Due to the complexity of her needs, Millie’s doctor urged her family to obtain in-home nursing services to keep Millie safe and healthy.
Millie’s family struggled with roadblocks trying to get in-home nursing services from the beginning. First, Millie’s insurance company inappropriately delayed the review of her doctor’s request for the nursing services. While the family continued to wait for a decision from the insurance company, Millie was in and out of the hospital with complications. This is when PHLP stepped in. We worked with the insurance company’s legal counsel to push the prior authorization review process through so that the insurer would reach a decision on whether or not Millie should receive nursing.
Unfortunately, the roadblocks did not end there. When the insurer finally made a decision, they denied the nursing services the doctor had prescribed. We helped Millie’s family file an appeal and agreed to represent her in the proceeding.
Millie’s doctor had requested 9 hours per day of in-home nursing services to be used while Millie’s father was working and her mother was caring for her older siblings, one of whom is diagnosed with Autism. These hours would also allow the nurse to go with Millie to her medical appointments, all of which were over an hour away from the family’s home. The insurance company felt that, although Millie clinically qualified for nursing services, her mother was able and available to provide for Millie’s skilled care needs during the 9 hours per day in question. We worked with Millie’s family and home health agency to get updated documents that explained the family dynamics and the need for hours – mainly, that Millie’s mother simply could not safely care for Millie, given the complexity and precarious nature of her medical needs, while also caring for multiple other children. We continued our appeal preparation by getting Millie’s mother and her clinical nurse manager ready to testify at the hearing.
Our preparation paid off. The denial was overturned at the appeal hearing and the insurer finally agreed to approve the prescribed 9 hours per day of nursing. Since getting nursing services in her home, Millie has been able to remain out of the hospital and stay at home with her family where she is loved and cared for.