Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral Neuropathy, Peripheral Vascular Disease
 
Treatment: Increase in Personal Care Services 

The insurer denied the Increase in Personal Care Services. The denial was reversed.
  
This is a male patient with a medical history of diabetes mellitus, hypertension, asthma, hyperlipidemia, and onychomycosis. It was reported that the patient had a motor vehicle accident years earlier that left him with chronic back pain. He has been under the care of a podiatrist for his diabetic peripheral neuropathy. He reported having numbness on bottom of his feet, as well as heavy and weakness making it difficult to walk. He consulted a vascular surgeon. Upon evaluation it was documented he had signs of vascular insufficiency with decreased pulses in his feet and edema. It was further noted that he had impaired balance that was associated with diabetic neuropathy, and increases his risk of falls. The patient is requesting an increase in personal care services to 12 hours/day 7 days a week. 

The UAS from late 2019 includes assessment of patient's functional status which indicates need for substantial assistance for most IADLs and ADLs. He is dependent on caregiver assistance for household tasks, shopping, transportation; and limited assistance for medications (he is unable to open bottles, indicating some type of motor and/or sensory loss in his hands). For mobility and locomotion, the patient is mostly wheelchair bound. For ambulation, he needs extensive assistance. This is consistent with the history noted by the podiatrist and vascular surgeon (numbness, heaviness of feet, loss of balance). When the aide is present he is assisted with all IADLs and ADLs. However, when the aide is not present (17 hours per day) all activities must be done without assistance. This includes change of clothes for bed, evening hygiene, transfer into bed, toileting (the latter is most likely needed several times in 17 hours). 

The patient's current safety plan includes a PERS and leaving his door open to call his neighbors for help. For a person who is known to have frequent falls, this is not an acceptable plan.  Calling for emergency help after the fall occurs is necessary; but when someone is having this many falls, there needs to be modification of the patient's care plan to help prevent falls from occurring. The UAS nurse noted patient's home is uncluttered, clean, well lit, so this is not the problem. The patient has chronic medical conditions causing functional limitations. Considering the patient's functional status, the patient's current care plan, i.e. personal care services 7 hours per day, is not sufficient to meet his needs for assistance and safety with ADLs. The patient needs high level of assistance for most daily activities, including those that occur at various, unscheduled times (i.e. transfers, walking, toileting). 

The patient has substantial functional impairments due to his medical conditions and associated symptoms. When he is alone, performing ADLs properly and safely is beyond his functional capacity. The result is a high level of burden to complete daily activities; and he has experienced the dangers of this situation with multiple falls. Therefore, it is medically necessary and in the best interest of the patient to have caregiver assistance for all ADLs that occur throughout the day.  Without consistent, reliable help from informal caregivers, then personal care services are indicated to provide the necessary assistance with ADLs. 

Based on the above, the medical necessity for an increase to 12 hours per day, 7 days per week, total 84 hours per week, Personal Care Services, level 2 is substantiated.  The insurer's denial is reversed.