Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional decline.
Treatment: Personal Care Assistance services a total of 40 hours.

The insurer denied coverage for Personal Care Assistance services a total of 40 hours.  
The denial is overturned.

This is a very elderly female with an assessment documenting that the patient had some cognitive difficulties with new situations, had short-term memory problems, and was described as forgetful.  She had minimal difficulty with hearing and adequate vision.  She needed supervision with managing medications, limited assistance with using a phone, and extensive assistance for navigating stairs.  She required maximal assistance for shopping and extensive assistance for transportation.  She needed extensive assistance with bathing, personal hygiene, dressing the upper and lower body, walking, locomotion, toileting transfers, and toileting use.  She needed supervision for bed mobility but was independent for eating.  She walked using an assistive device and had a decline in her activities of daily living status as compared to 90 days prior.  She had also deteriorated, and overall self-sufficiency as compared to 90 days prior. 

The patient had infrequent bladder incontinence but no bowel incontinence and was using the toilet hourly.  She had 1 fall in the last 30 days with no injuries and had exhibited some dizziness and an unsteady gait.  The report stated that the patient's daughter and granddaughter visit the member to support her emotionally and keep her company, but they are unable to assist her as they have other responsibilities.  The patient was hospitalized recently for bile duct removal, endoscopy, and stent placement in the gallbladder.  She had septic shock and was discharged on the date of the assessment.  The patient had multiple diagnoses with active treatments for several.  

Compared to a prior assessment the patient's condition had deteriorated.  

The patient is at risk for falls and fractures due to her gait instability, chronic pain, and osteoporosis.  It was determined that the patient would benefit from an increase in her home health aide hours.  At the time of discharge, the patient's ambulation distance was limited to less than 50 feet with seated rest breaks using a four-wheel walker.  She needed a contact-guard for safety due to decreased foot clearance and required moderate assistance to perform sit to stand transfers from the couch and from the toilet seat.  The patient requires assistance with bathing, dressing, toileting, and hygiene due to decree strength in the bilateral lower extremities, decreased active range of motion of the trunk with inability to bend and twist and requires total assistance for reaching her feet for hygiene.  She needs assistance to stand up from the toilet and has decreased activity tolerance to less than 5 minutes after which she needs assistance to get soap, toothpaste, toothbrush, towel, and close as needed.  The patient requires total assistance to prepare her own meals, cook, and clean her home and requires verbal prompting for medication management due to increased cognitive deficits.  

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 Assistance services a total of 40 hours week services is substantiated.