Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right sided hemiplegia, dementia, diabetes mellitus type 2, high blood pressure, history of cerebral vascular accident (x2) and congestive heart failure. 

Treatment: Personal Care Services, the patient requested 24 hours a day, 7 days a week, for a total of 91 hours weekly. 

The insurer denied coverage for Personal Care Services (PCS), the patient requested 24 hours a day, 7 days a week, for a total of 91 hours weekly. 

The denial is overturned. 

This female has been residing in a skilled nursing facility (SNF). The available records do not fully explain her reason for admission. She has extensive medical history associated with functional impairment and needs assistance with all daily activities. The patient's son reports that the patient and her family want her to return home with home care services. The insurer's final denial letter indicates approval was initially given for personal care services (PCS) 34 hours per week. The patient (via designee) requested PCS 24 hours per day live-in, which was denied; but the insurer increased PCS to 56 hours per week (8 hours per day, 7 days per week). The patient's son requested an external appeal.

The most recent UAS (uniform assessment system) provided for review was done at the SNF. The functional status for IADLs (independent activities of daily living) indicated patient was totally dependent or needed maximal assistance for all IADLs, except phone use: extensive assistance. The patient needed extensive assistance for most ADLs (activities of daily living), except bed mobility and eating: limited assistance. 

Based on the patient's medical history and functional status, it is medically necessary for the patient to have assistance with all daily activities when they are needed throughout the day and night. This includes household related tasks; meal preparation and service of all 3 meals per day; assist with eating as needed; assistance/reminders with medications and glucose finger sticks; assist with bathing daily, and personal hygiene and dressing morning and evening. Some help is needed at night when she is in bed to help reposition for pressure relief. She needs assistance with tasks that occur at unscheduled and recurring times of the day/night, including toileting/incontinence care and mobility around the home. This level of care and frequency of caregiver assistance is necessary to help ensure adequate food and fluid intake; decrease risk of hypoglycemia; decrease risk of pressure injuries and complications from inadequate toileting/incontinence care (skin damage); help decrease occurrence of falls and injury. 

The patient has been living in a nursing home. Her functional status prior to SNF admission is not clearly described in the available records, but there is most likely going to be a transition period in which the patient will need to re-adjust to living at home. Although the aides in the SNF did not provide 1:1 care, the patient had assistance for all her daily activities throughout the day and night. Based on UAS and SNF records, the patient needs some level of assistance and supervision for all daily tasks. The full extent of her care needs will be clarified after she is home and is participating in all daily activities in her home again. Based on available information, the patient's care needs support 24-hour personal care services, as she needs assistance with various activities through day, evening and night hours as previously described in this review. 

NOTE:  Recommendation to approve personal care services 24 hours per day live-in is contingent on the following conditions: 

1) The patient is determined to be medically stable for discharge home by the patient's SNF physician. 

2) The patient's personal care needs can be properly and safely managed by one aide. 

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

The insurer's denial of coverage for Personal Care Services, the patient requested 24 hours a day, 7 days a week, for a total of 91 hours weekly and the plan approved 8 hours a day, 7 days a week, for a total of 56 hours a week is overturned. Medical Necessity is substantiated.