Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, hypertension, osteoporosis and fragility fracture, stroke, meningioma, seizure, dementia, atrial fibrillation (on anticoagulation) and falls
Treatment: 24 hours per day, 7 days per week (split-shift); total 168 hours per week of personal care services
The insurer denied coverage for 24 hours per day, 7 days per week (split-shift); total 168 hours per week of personal care services.
The denial is overturned.
 
This case involves a patient with a subject of review for 24 hours per day, 7 days per week (Split-shift). A total of 168 hours per week of personal care services, Level 2.

The patient was seen for a checkup following her unwitnessed fall. It was noted that she has a history of dementia and frequent falls. Currently on Eliquis. She typically ambulates with a walker. Computed tomography (CT) Head revealed no evidence of intracranial mass lesion, acute territorial infarct, or intracranial hemorrhage. CT Spine showed no traumatic fracture. The patient is noted to be alert and oriented x1 on exam. 

According to the appeal request form, the patient has multiple falls, urinary incontinence, bradycardia, seizure disorder, heart failure, coronary artery disease, cerebrovascular accident, paroxysmal atrial fibrillation, abnormal electrocardiogram. Her clinical and physical needs exceed the hours that she currently has in place. Requesting to provide 168 hours of care as the patient has fallen due to the overnight hours. 

The healthcare plan did act reasonably and with sound medical judgment as well as in the best interest of the patient at the time the decision was made to reduce care hours. However additional information was received from the treating provider that indicates the patient no longer is residing in a rehab center. As the patient's living situation now indicates she is residing alone in an apartment with an elevator building, the original health plan denial decision is no longer reasonable and supported with sound medical judgment or in the best interest of the patient.

24 hours per day, 7 days per week (split-shift); a total of 168 hours per week of personal care services considered medically necessary for this patient.

According to the progress notes, the patient now lives alone at home and receives personal care services from a home health aide. The patient is noted to be alert and oriented x1 on exam. Given the patient's condition ambulation is compromised by her osteoarthritis, hemiplegia, and dementia. The patient's mobility limitation significantly impairs her ability to participate in mobility related activities of daily living (MRADLs), including walking independently. Without ambulatory assistance, the patient is entirely unable to complete ADLs. In addition, the medical records support the patient recently had 2 hospitalizations after falling overnight while trying to go to the bathroom. The medical records support the patient's cognitive status in conjunction with physical health, places the patient at an elevated risk for further falls or injury. Therefore, the request for 24 hours per day, 7 days per week (split shift); a total of 168 hours per week of personal care services, is considered medically necessary.

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 24 hours per day, 7 days per week (split-shift); total 168 hours per week of personal care services is substantiated.