Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes, coronary artery disease, atrial fibrillation, osteoporosis, polyarthritis and memory lapses. 
Treatment: Personal Care Services, 12 hours per day, 5 days per week, 6 hours per day, 2 days per week, total 72 hours per week. 
The insurer denied coverage for Personal Care Services, 12 hours per day, 5 days per week, 6 hours per day, 2 days per week, total 72 hours per week. 
The denial is overturned.  

This is an older adult with chronic medical problems including hypertension, diabetes, coronary artery disease, atrial fibrillation, osteoporosis, polyarthritis and memory lapses.  She lives alone in a private residence. The patient is currently receiving 42 hours per week of personal care services (PCS), as well as 2 days/week (total 8 hours/week) of social day care.  The request is for PCS; 12 hours/day, 5 days/week, 6 hours/day, 2 days/week, total 72 hours/week. 

The Uniform Assessment System (UAS) report was reviewed. The assessment was performed via video teleconference. The assessment noted that the patient's cognition was "modified independent" and the patient was "self-directing. Able to activate personal emergency response system (PERS) or call 911 in case of emergency." The patient was reported to require extensive to maximal assistance for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient was reported to  require extensive assistance for bathing and lower body dressing. Limited assistance was  needed for personal hygiene, upper body dressing, locomotion, toilet transfer/use and ambulation. The patient was independent for bed mobility and eating. The patient was frequently incontinent of bladder and continent of bowel. The patient's ability to perform activities of daily living (ADLs) and self-sufficiency had reportedly not changed and there had been no reported falls over the prior 90 days. 

The letters from the patient's treating physicians requesting additional home care services were reviewed. There is a treatment note from a third physician. The patient presented for follow-up evaluation and treatment of anxiety and dementia, and was described as "alert and oriented, understood commands well." However, "Attention span and concentration were impaired." The patient's gait was described as "broad based and ataxic." 

The patient is of advanced elderly age, lives alone and requires "assistance - guided maneuvering of limbs, physical guidance without taking weight" for personal hygiene, walking/locomotion, and transfer toilet/toilet use. Furthermore, the patient's cognitive (according to the treating physician's notes) and physical (per the UAS report) impairments are substantial, supporting an increase in Personal Care Services to 12 hours per day, 5 days per week and 6 hours per day, 2 days per week, total 72 hours per week. 

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 Services (PCS) 12 hours per day, 5 days per week, 6 hours per day, 2 days per week, total 72 hours per week services is substantiated.