Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Frequent Urinary Tract Infections

Treatment: Personal Care Services (PCS) 12 hours per day - 7 days per week (split shift) for a total of 168 hours/week

The insurer denied coverage for Personal Care Services (PCS) 12 hours per day - 7 days per week (split shift) for a total of 168 hours/week

The denial is overturned

This is an elderly patient with chronic medical problems including atrial fibrillation, urinary tract infections (UTIs) and depression. The patient lives alone in a 1-bedroom apartment and was discharged from a rehabilitation facility recently. The insurer approved personal care services (PCS) 8 hours per day, 7 days a week, for a total of 56 hours per week. The request is for PCS 12 hours per day - 7 days per week (split shift) for a total of 168 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as minimally impaired. The patient reportedly requires maximal assistance to total dependence for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is also reportedly total dependent for locomotion. The patient reportedly requires maximal assistance for bathing, dressing and toilet transfer/use. Extensive assistance is reportedly needed for personal hygiene and bed mobility. Limited assistance is reportedly needed for eating. The patient reports being frequently incontinent of bladder and bowel. The patient's ability to perform activities of daily living (ADL) and self-sufficiency have reportedly declined and deteriorated, respectively, over the prior 90 days.  There was one reported fall over the prior 30 days.  The UAS report (when the patient was a nursing facility resident) was reviewed.  The patient's cognitive ability is much the same; however, their functional ability has declined for many ADL tasks. There are logs from the nighttime supporting the patient having multiple episodes of needing to use the bathroom/needing a diaper change.

The patient's clinical condition and functional deficits are at a level and unpredictable as to require the requested PCS 24 hours/day (split shift).  A letter from the patient's treating physician describing the patient's clinical condition and reported need for "assistance 7 days a week, 24 hours per day and night" was reviewed.  

Based on the submitted clinical records, the patient's health and safety are more appropriately provided and maintained at home by the requested PCS 12 hours per day - 7 days per week (split shift) for a total of 168 hours/week. The nighttime logs suggest that an aide would not be able to obtain 5 hours of continuous, uninterrupted sleep.

From a physical medicine and rehabilitation perspective, PCS 24 hours a day - 7 days a week (split shift) for a total of 168 hours a week is medically necessary.    

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours a week is substantiated.