Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cerebrovascular accident, hemiplegia

Treatment: Personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours a week

The insurer denied coverage for personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours a week. 

The denial is modified.

This is a patient with medical problems including hypertension and stroke with hemiplegia.  He lives alone in a private residence.  The patient has a spouse that reportedly does not live with them.  The patient was previously approved for personal care services (PCS) 7 days/week, 24 hours/day, live in (91 hours/week) and the insurer decreased the PCS to 9 hours per/day, 7 days/week (63 hours/week).  The patient is seeking reinstatement of the PCS 7 days/week, 24 hours/day, live in (91 hours a week). 

The Uniform Assessment System (UAS) finalized report was reviewed.  The patient's cognitive skills are described as minimally impaired.  The patient reportedly requires maximal assistance to total dependence for much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient also reportedly requires maximal assistance for bathing, upper body dressing, toilet transfer, locomotion and ambulation (he uses a cane).  Extensive assistance is reportedly needed for personal hygiene, lower body dressing, bed mobility, eating and  toilet use.  The patient is reportedly occasionally incontinent of urine and continent of bowel.  The patient's activities of daily living (ADL) status and self-sufficiency have reportedly not changed and there have been no reported falls over the prior 90 days.   

The patient's medical condition, physical limitations and functional ability are not at the level or unpredictable as to require maintaining live-in PCS (personal care services).  The records reviewed are consistent with a higher level of function than described by the UAS (Uniform Assessment System) report, particularly for mobility.  The associated treatment and progress notes were not included for review and would have been helpful.  The letter from the patient's brother was also reviewed.  This physician would agree the patient may benefit from additional monitoring; particularly due to his reported weakness and falls risk.  However, safety monitoring under PCS (personal care services) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  Based on the records reviewed and discussed above, attention to the patient's health and safety can be appropriately provided and maintained by modestly increasing PCS (personal care services) to 11 hours/day (perhaps 2 separate shifts), 7 days/week totaling 77 hours/week.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  

Based on the above, the insurer's denial must be modified. 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, 24 hours a day, 7 days a week (live-in) for a total of 91 hours a week is not substantiated. However, increasing PCS 11 hours a day, 7 days a week (77 hours) is medically necessary.