Appeal type: Medical necessity
Decision: Upheld

Diagnosis: congestive heart failure (CHF)

Treatment: personal care services(PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week

The insurer denied coverage for personal care services(PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week

The denial is upheld
 

This case involves an elderly patient with a subject for review for the denial of coverage for personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week.

It was noted during the telemedicine visit that the patient has trouble breathing when she lays back. She also reported persistent cough. She was sent home on oxygen as her saturations were low and dropped to 88% (percent) on room air. 

Imaging showed congestive heart failure (CHF) and a possible small left pleural effusion. 

An appeal letter was submitted by the patient's family for the request to increase the member's personal care services. In the letter, the family stated that the patient is unable to operate the nasal cannula herself, unable to get out of the hospital bed herself to get to the commode, and she needs additional toileting at night due to the water pill. 

In this case, the patient with a diagnosis of CHF, lives alone in a 1-bedroom apartment building that is handicap and wheelchair accessible. She is alert and oriented with periods of forgetfulness and is able to activate emergency response in the event of an emergency. She is not able to stand or walk independently but is able to make a few steps to transfer from surface to surface.

The patient stated that there is an increase in needs at night which requires additional assistance. The appeal letter submitted by the family for the request to increase the personal care services stated that the patient is unable to operate the nasal cannula herself, unable to get out of the hospital bed herself to get to the commode, and she needs additional toileting at night due to her water pill. During the assessment, the nurse educated the member on proper genital care such as wiping from front to back, and explained the importance of keeping the genital area clean and dry for incontinence and supplies are provided to help the patient remain clean and dry. The bedside commode can always be placed near the member to provide convenience and safety whenever needed as the patient is able to make few steps to transfer from surface to surface. The nurse can re-educate her on how to operate nasal cannula for use at night.

The approved 12 hours a day, 7 days a week for a total of 84 hours per week is sufficient to meet the patient's needs and goals such as meal preparation, ordinary housework, shopping, bathing, personal hygiene, dressing the upper body, dressing the lower body, locomotion, transfer toilet, toileting, bed mobility, and eating. As such, the denial of coverage for personal care services 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week is upheld and is considered not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care services 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week is not substantiated.