Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory failure, pulmonary obstruction, frequent urinary tract infections, anemia, chronic heart failure. 
Treatment: Personal care services (PCS) - 24 hours a day, 7 days a week, (split shift). 

The insurer denied coverage for personal care services (PCS) - 24 hours a day, 7 days a week, (split shift). 

The denial is overturned. 
 
This case involves an elderly female with a history of hypertension, falling, muscle weakness, insomnia, and hypothyroidism who was seeking coverage for 24 hours a day, 7 days/week, split shift, for personal care services (PCS).  Records stated the patient lives with her disabled spouse, and that both are receiving home care services in the amount of 12 hours/day.  The patient's spouse has significant health problems, and the patient herself has chronic hypercapnia with respiratory failure, pulmonary obstruction, frequent urinary tract infections, anemia, chronic heart failure, major depression with psychosis, and altered mental status, which has resulted in "great confusion" and resultant blood gas irregularities/issues.  Her mental health, cardiac, and pulmonary diseases are chronic and will not improve.  The patient had a decline in health and had a new plateau requiring additional and optimum care and assistance 24 hours/day.  

An appeal was submitted stating that the patient has multiple conditions/comorbidities and her mental health, cardiac and pulmonary diseases are chronic and will not improve.  The report stated that the patient had a complication due to nasal packing, which prevented her from wearing bilevel positive airway pressure (BiPAP) for several nights.  With nasal packing, the patient could aspirate with the air pressure.  This created additional confusion, physical and mental decline and difficulty for the patient for several days.  This led to the patient pulling out her Foley catheter, causing additional trauma and harm to herself and required the patient to be placed on enhanced supervision.  This meant that a staff member had to be in the patient's room 24 hours a day to assist her.  The staff attempted to take the patient off supervision several times in hopes that the rehabilitation facility would readmit her without success.  The physician stated the patient is exceptionally upset, scared, anxious when left alone, which causes her pulse oxygen levels to lower, placing her at medical risk.  The patient is considered an individual who must use a bilevel positive airway pressure (BiPAP) to remain alive, was not sleeping much at night, is confused, and requires full assistance in the bathroom for toileting.  She must be turned and positioned in the bed by another person whether awake or asleep and has developed a bedsore on her buttocks due to a lack of repositioning at night (per family note).  The report stated that the patient and her spouse were living in the basement of a home as it is the only place where there is a handicap accessible bathroom and room for a bed.  The other bedrooms in the house are 2 floors up.  The patient is not asking for a live-in aide because even with monitors, the aide cannot always get to the basement in time to assist the patient.  The physician stated that there are no devices that can replace the needs of a personal caregiver and she would require 24-hour split shift to meet the medical needs of the patient.  

Based on the above, the insurer's denial must be overturned. 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) is substantiated.