Appeal type: Medical necessity
Decision: Overturned

Diagnosis: abnormality of gait, anxiety, bilateral leg edema, blurred vision, breast cancer, cirrhosis, chronic pain of both ankles, class III severe obesity, osteoarthritis, and falls.

Treatment: Personal Care Services (PCS), 7 hours a day, 5 days a week and 5 hours a day, 2 days a week, for a total of 45 hours.

The insurer denied coverage for Personal Care Services (PCS), 7 hours a day, 5 days a week and 5 hours a day, 2 days a week, for a total of 45 hours.

The denial is overturned.

 
This case involves an elderly female with a history of abnormality of gait, anxiety, bilateral leg edema, blurred vision, breast cancer, cirrhosis, chronic pain of both ankles, class III severe obesity, osteoarthritis, and falls.  Records stated that the patient was hospitalized due to shortness of breath and cough.  She was subsequently discharged with a diagnosis of pneumonia and atelectasis of the right lung and a fracture of the right lower ribs.  Her physician recommended that she receive an increase in the number of home health hours.  

The patient had been scheduled for surgery but had to cancel as she needed time to recover from the 2 hospital visits.  The physician noted that the patient lives alone and does not have any family or community support.  She is unable to independently ambulate and requires a rollator or wheelchair for mobility.  The patient cannot complete any daily tasks while walking with her device and requires someone to propel her in the wheelchair.  The patient is unable to stand for prolonged periods nor is she able to walk long distances or navigate stairs.  The patient can no longer safely leave the home alone for appointments or any leisure trips.  She has a history of numerous falls in her home resulting in being on the floor for long periods of time or resulting in hospitalizations.  

Record stated the patient was admitted to the hospital recently.  She was diagnosed with pneumonia and atelectasis of the right lung with fracture of the right lower ribs.  Discharge instructions noted the patient would require 4 liters (L) of oxygen at home.  Given her history of falls leading to previous emergency department visits, a request was submitted for an increase in the number of home health-aid hours.  A letter stated that the patient ended up back in the hospital.  She was previously discharged from the hospital on home oxygen but was never taught how to use it.  Her insurance never reinstated the home health aide services and she had been without a home health aide since her discharge.  A community para medicine team went to the patient's home and found her to be hypoxic whereupon she was taken to the emergency room. 

The documentation provided for the review noted that the patient was previously approved for 17 hours weekly of personal care services.  While she was initially denied coverage for an increase to 45 hours weekly following an assessment, given that the patient had documented evidence of recent hospitalization with diagnoses consisting of pneumonia and atelectasis of the right lung with fracture of the right lower ribs, and then an additional hospitalization for hypoxia, a temporary increase to 45 hours weekly of personal care services would be within the standard of care.  

Based on the above, the insurer's denial must be reversed. 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), 7 hours a day, 5 days a week and 5 hours a day, 2 days a week, for a total of 45 hours is substantiated.