Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoporosis, hearing loss, hypertension, and osteoarthritis

Treatment: Personal Care Services (PCS) 9 hours a day, 5 days a week for a total of 45 hours a week

The insurer denied coverage for Personal Care Services (PCS)  9 hours a day, 5 days a week for a total of 45 hours a week

The denial is overturned.

 
This elderly patient is functionally impaired due to various medical conditions and needs assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone. She has personal care services (PCS) 6 hours per day, 4 days per week; 4 hours per day, 1 day per week; total of 28 hours per week. As per the UAS, the daughter (as informal helper) provides care to her mother on weekends. The patient (via designee) requested increase of PCS to 9 hours per day, 5 days per week, total of 45 hours per week, which was denied.

The Uniform Assessment System (UAS) provided for review was done several months ago. The functional status report for IADLs indicated the patient needed maximal assistance for meal preparation, ordinary housework, managing finances, shopping; extensive assistance for transportation, managing medications, phone use, stairs. For ADLs, the patient needed extensive assistance for bathing, personal hygiene, dressing upper and lower body, walking, locomotion; limited assistance for toilet use, transfer toilet, bed mobility, eating.

The UAS reports patient has osteoarthritis. Specific joints are not identified, but it is noted in the UAS that limited range of motion (ROM) is one of the reasons the patient needs help with ADLs and IADLs. The patient needs assistance with bathing, dressing, personal hygiene, toileting. Pain and stiffness to upper and lower extremity joints can affect these ADLs. The physician's letter reports patient has cervical and lumbar degenerative disc disease associated with neck and lower back pain. Lower back pain can affect mobility (transfers, walking) and lower body ADLs (dressing, bathing). 
The UAS indicated patient has pain daily. The UAS medication list includes Motrin and Extra Strength Tylenol. Current frequency and severity of pain is not known from the available records, but arthritis and degenerative disc disease are chronic progressive conditions. It is likely the patient still has pain and functional limitations associated with these conditions.

As per UAS, the patient needs limited assistance with toilet transfer.  The physician reported patient has lower back pain. The UAS reports patient has difficulty moving to a standing position unassisted. She also has poor balance and episodes of dizziness. These issues suggest a higher level of assistance may be needed for toilet transfer, especially when symptoms of back pain and dizziness are worse. The patient needs extensive assistance walking to the bathroom. As noted, she refuses assistive device and depends on furniture and caregiver assistance. When she is alone, she can only rely on furniture, which may not provide adequate support. During daytime hours, a commode chair is not an adequate solution, as the patient is most likely not in bed or at one location in the home next to the commode chair all day. 

Recommendation is given to approve Personal Care Services 9 hours per day, 5 days per week for a total of 45 hours a 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) 9 hours a day, 5 days a week for a total of 45 hours a week is substantiated.