Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dementia, diabetes mellitus
(DM), history of cardiovascular accident (CVA),
and muscle weakness
Treatment: Increase in Personal Care Services (Level 2) to 24 Hours Per Day, 7 Days Per Week (Live-In)
The insurer denied the Increase in Personal Care Services (Level 2) to 24 Hours Per Day, 7 Days Per Week (Live-In)
The denial is overturned.

This male has conditions including coronary artery disease (CAD), hypertension (HTN), Parkinson's disease, dementia, benign prostatic hypertrophy (BPH), epilepsy, diabetes mellitus (DM), asthma, cardiovascular accident (CVA), recurrent urinary tract infection (UTI), and  muscle weakness. He is appealing denial of 24 hours per day of personal care services (PCS).  He received partial approval of up to 12 hours per day.  He lives with his wife who receives personal care assistance.  Uniform Assessment System (UAS) evaluation performed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, phone use, and shopping; maximal assistance with managing medications, bathing, lower body dressing, and toilet use; extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and bed mobility; and limited assistance with eating.  He requires a rolling walker and one-person assist at all times.  He uses a wheelchair for longer distances.  He is frequently incontinent of bladder and occasionally incontinent of bowel.  He wears pull-ups and requires protective ointment applied.  Compared to UAS (Uniform Assessment System) evaluation performed previously, there has been a decline in phone use, bathing, lower body dressing, toilet use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and bed mobility.

A letter from the patient's provider notes recent subarachnoid hemorrhage, status post a fall and COVID-19 and notes significant decline in functional, cognitive and medical status.  The letter states the patient requires extensive assistance with activities of daily living (ADLs) and requires frequent toileting assistance and changing. It is recommended the patient receive 24 hours of split shift care.  

A letter from a second provider notes the patient was admitted for short-term rehabilitation (prior admission was receiving 9 hours per day of home care services) and since that time has significant decline in functional, cognitive, and medical status.  It is stated he requires frequent toileting assistance and changing. Twenty-four hour live-in services are recommended.

Yes, the proposed increase in personal care services (PCS) to 24 hours per day, 7 days per week (live-in) is medically necessary.
Medically necessary services are those which are safe, effective, a generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, and the least intensive and/or most appropriate alternative(s) among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standards of medical practice.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding.  Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  

This patient has multiple chronic conditions including dementia and hospitalization for COVID-19.  He lives with his wife who receives personal care services.  The patient is appealing denial of personal care services (PCS), 24 hours per day.  He received partial approval for an increase to 12 hours per day.  Uniform Assessment System (UAS) evaluation performed shows the patient requires assistance with all activities of daily living (ADLs)/independent activities of daily living (IADLs).  This evaluation shows a decline in the patient's functioning when compared to the Uniform Assessment System (UAS) evaluation performed previously.  There has been a significant decline in the patient's functional status where he now requires more assistance with phone use, bathing, lower body dressing, toilet use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and bed mobility from extensive to maximal assistance and requires a walker as well as one-person assistance with transfers and ambulation.  He is incontinent of bladder and has demonstrated the need for maximal assistance with ambulation/transfers for toileting.  Other than limited assistance with eating, the patient requires extensive assistance to total dependence with all activities of daily living (ADLs)/independent activities of daily living (IADLs).  This patient has continuous needs that cannot be met with the approved 12 hours per day of personal care services (PCS).  The proposed increase to a 24 hours per day (live-in) of personal care services (PCS) is medically necessary to meet this patient's need for assistance with activities of daily living (ADLs) and personal care.