Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation, recent COVID-19 infection, coronary heart disease, diabetes and depression. 
Treatment: Increase Personal Care Services-24 Hours A Day 7 Days A Week (live-in) A Total of 91 Hours (health plan approved 56 hours/week). 

The insurer denied the Increase Personal Care Services-24 Hours A Day 7 Days A Week (live-in) A Total of 91 Hours (health plan approved 56 hours/week). 

The denial is overturned. 

The patient is a female. Her conditions include atrial fibrillation, recent COVID-19 infection, coronary heart disease, diabetes and depression. Denial of increase in personal care services (PCS) to 24 hours a day 7 days a week, live-in, a total of 91 hours, is being appealed. The health plan approved 56 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with managing medications, phone use, transportation, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and extensive assistance with bed mobility and eating. She has frequent bladder incontinence. She had no falls documents in the prior 90 days. 

A statement by the patient's provider notes the patient was admitted a few months ago with COVID. Her hospital course was complicated by pneumonia. Since discharge, she has not returned to her prior level of functioning. She no longer ambulates and requires a wheelchair. She needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. They recommend 24 hour care. 

A statement by another provider notes the patient has impaired mobility. She is unable to use a walker safely to complete MRADLs (mobility-related activities of daily living). Wheelchair is required for bathing, use of bathroom and transferring in and out of bed. She is unable to self-propel. 

Yes, the Increase Personal Care Services-24 Hours A Day 7 Days A Week (live-in) A Total of 91 Hours is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase in PCS (personal care service) to 24 hours a day 7 days a week, live-in, a total of 91 hours, is being appealed. The health plan approved 56 hours per week. 

This patient has multiple chronic medical conditions. UAS (Uniform Assessment System) evaluation completed shows the patient requires extensive to maximal assistance with all ADLs (activities of daily living). She has bladder incontinence. The appeal statements note that the patient's functioning has not returned to baseline since hospitalization a few months ago. She is no longer ambulatory.  She requires the wheelchair for transferring, locomotion and with ADLs (activities of daily living). She is unable to propel the wheelchair. This patient requires significant assistance with ADLs (activities of daily living) and personal care. Based on this patient's limitations and her level of functioning, the approved PCS (personal care service) 56 hours per week is insufficient to meet her needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in PCS (personal care service) to 24 hours, live-in, is medically necessary.