Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Amyloidosis.
Treatment:  24 hours per day, 7 days per week (split-shift), total of 168 hours per week, Personal Care services, Level 2.

The insurer denied coverage for 24 hours per day, 7 days per week (split-shift), total of 168 hours per week, Personal Care services, Level 2.  The denial is overturned.

This case is regarding the denial of coverage for 24 hours per day, 7 days per week (split-shift), total of 168 hours per week, Personal Care services, Level 2.  The assessment was conducted the patient lives with their spouse in a 2 bedroom, second-floor, private home.  There were 6-7 steps into the house, and the patient has a stair lift to access the second floor.  The home was clean and clear of clutter and safe to provide home care services.  The patient had modified independence for cognitive skills for daily decision making with some difficulty in new situations only.  Otherwise, the patient's memory was okay.  The patient was alert and oriented x3, and at times, experienced episodes of forgetfulness, and was self-directing.  In terms of communication, the patient was usually understood but found it difficult to find words or finish thoughts, but if given time, required little or no prompting. The patient had adequate hearing and vision with the ability to read with reading glasses.  There were no behavioral or mood issues documented.  The patient was diagnosed with amyloidosis recently and had multiple hospital admissions in the past 90 days.  The patient has a privately paid aide who helps 24/7.  The patient was totally dependent for meal preparation and ordinary housework and needed limited assistance with managing finances.  The patient required extensive assistance for managing medications, phone use and was totally dependent for stair navigation and shopping. The patient needed maximal assistance for transportation and was totally dependent for bathing, personal hygiene, and dressing the upper and lower body.  The patient was totally dependent for locomotion and toilet use.  The patient required extensive assistance for bed mobility and eating.  The patient was considered bedbound with a decline in activities of daily living status as compared to 90 days prior.  

Personal assistant services (PAS) allow patients to remain in the comfort of their own home to receive care/treatment rather than residing in a skilled nursing facility, long-term acute care, or assisted living.  The documentation provided for the review noted that the patient was bedbound and was totally dependent for several activities of daily living/instrumental activities of daily living.  He needed extensive assistance or maximal assistance for other services on a daily basis due to his health conditions.  The assessment conducted noted a decline in the patient's health/condition as compared to 90 days prior.  Based upon the provided information, it was determined that because the patient requires care 24/7 to prevent breakdown of skin given the patient's physical state and the inability to reposition themselves throughout the day and night, with the findings that they required a foley bag and had incontinence of the bowel, placing the patient at further risk of skin breakdown.  The patient's spouse is unable to provide the care needed given their own health issues, and in taking the age of the patient into consideration as well as the notation that their condition had deteriorated since the last assessment, the recommendation for 24 hours per day, 7 days per week (split-shift), total of 168 hours per week, Personal Care services, Level 2 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 24 hours per day, 7 days per week (split-shift), total of 168 hours per week, Personal Care services, Level 2 is substantiated.