An Argument for Coverage of Lactation Consultation
A while back I published a bit about how to get insurance appeals approved. So here’s a specific example. This regards a young woman who delivered her first infant and was having trouble breastfeeding. After discharge, her physician recommended home lactation consultation services, which her insurer denied as not medically necessary. The patient’s policy did cover “skilled” medically necessary home health service , but not “custodial” care, defined as care meant for ongoing maintenance or assistance with daily living.
So here’s an answer to that (nonsense).
Typically, home health services are provided because the patient cannot leave their home to obtain those services, but lactation consultation is a different issue. Lactation services are either provided in the hospital while the patient is inpatient, or in the home after discharge. Most communities do not have facility to provide lactation consultation on an outpatient basis, other than through various licensed or unlicensed practitioners such as doulas or (some) midwives. As such, once a patient has left the hospital home health is the best option for this service, for most patients.
Furthermore, the provided policy does not specifically address lactation consultation specifically as either being a skilled service or a custodial service. If it were a skilled service and medically necessary, it would be covered.
While lactation consultation is not specifically addressed in plan policy, skilled services are defined as:
“A health service is determined to be skilled based upon whether or not clinical training is necessary for the service to be delivered safely and effectively and on the need for physician-directed medical care. Examples of clinical training include registered nurse, licensed practical nurse, respiratory therapist, physical therapist, occupational therapist, and speech therapist. This list is not all-inclusive.”
Based on this definition, lactation consultation would be skilled. Lactation consultation requires a specific certification, typically given along with RN, CNM, or LPN licensure. It cannot be provided by relatively untrained people such as certified nursing assistants.
Custodial care is defined as :
* Non-health-related services, such as assistance in activities of daily living (examples
include feeding, dressing, bathing, transferring and ambulating) – this is not the case here. The specific activity at hand is breastfeeding, which is not an activity of daily living for the patient. “feeding” in the policy refers to the patient feeding herself, not her infan.
* Health-related services which do not seek to cure, or which are provided during
periods when the medical condition of the patient who requires the service is not
changing. – This service does seek to “cure” a problem, in this case the problem being inability to breastfeed.
* Services that do not require continued administration by trained medical personnel in
order to be delivered safely and effectively. – This service does require trained medical personnel, with specific education on lactation education.
As such, lactation consultation is not custodial care.
Medical necessity of breastfeeding is clearly established, as while bottle feeding is an option, breastfeeding has been shown to be of substantial benefit to the infant, both in physical (growth, neural development, immune development) and psychological (mother-infant bonding) areas.
Based on plan coverage documents the requested 2 visits should be covered as a skilled service for this patient, under the provided coverage Documents.