Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease.
Treatment: Custodial or Long Term Care for multiple dates of service.
The health plan denied the requested Custodial or Long Term Care for multiple dates of service as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with a past medical history of diabetes mellitus type 2, seizure disorder, schizophrenia, substance abuse, chronic kidney disease, hypertension, asthma, glaucoma, and Parkinson's disease who was a patient at a long term care facility. 

The patient was seen by provider with progress note stating patient's hemoglobin a1c level was 11.3; the patient was treated with insulin. The patient was being treated with Eliquis, and he had eye drops for glaucoma and multiple medications for hypertension, seizure disorder, and Parkinson's disease. 

A psychiatrist saw the patient and noted the patient would need substantial support and supervision in the community, given the patient's past inability to effectively care for himself. The patient is able to state preferences, and may be more suitable for custodial/assisted living facility than a Skilled Nursing Facility (SNF), as the patient's capacity for medical and discharge decisions is diminished but not to the point that he cannot make some rational choices, and the patient had the right to be treated in the least restrictive environment as in a general population. The patient's case manager sent a letter appealing the denial decision noting the primary physician noted the patient needed substantial support and supervision in the community, given his past in ability to care for himself. The letter also stated the patient currently was having difficulty with bed mobility, transfers, and ambulation. In addition, the letter stated the patient would not be able to have his needs met with outpatient set-up or homecare program, as this would be impossible, as the patient is homeless. The case manager also stated custodial room and board is medically appropriate and necessary.

The health plan's determination of medical necessity is overturned, in whole.

The patient is medically disabled. Notes indicate the patient requires assistance with transfers. There is documentation of repeated medical noncompliance. The patient is not able to take his medication which is necessary to help with his significant mental health diagnoses of schizophrenia and anxiety. In addition, the patient has insulin dependent diabetes which would be out of control, as the patient is not compliant with medications when not in a supervised setting. The patient is taking anticoagulation and is at risk for falling if not assisted with transfers. The patient has history of seizure disorder and without medication he is at risk for injury or death. The patient would not be able to go to an adult living facility, as he requires a special diet and insulin administration with blood glucose checks. Furthermore, the patient is unable to have home based care because he is homeless. The patient's medical provider documented the patient needed substantial support and supervision in the community, given the patient's inability to care for himself and he was expected to deteriorate if discharged unsafely or against medical advice (AMA).