Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Progressive osteoarthritis of multiple joints, discogenic spine disease, depression, anxiety, dementia, lack of alertness, poor judgment, incontinence, coronary artery disease, atrial fibrillation, hypertension, congestive failure, 
varicose veins lower extremities, obesity, and impaired memory

Treatment: Personal Care Services: 10 Hours times 7 Days (or/between) 12 Hours times 7 Days a Week for a Total of 70-84 Hours

The insurer denied Personal Care Services: 10 Hours times 7 Days (or/between) 12 Hours times 7 Days a Week for a Total of 70-84 Hours.
The denial is partially overturned.

This patient is an elderly female with a history of progressive osteoarthritis of multiple joints, discogenic spine disease, depression, anxiety, dementia, lack of alertness, poor judgment, incontinence, coronary artery disease, atrial fibrillation, hypertension, congestive failure, varicose veins lower extremities, obesity, and impaired memory. The patient's daughter reports that the patient has become more psychotic as her dementia has progressed. She has been knocking on the doors of her neighbors and has been hallucinating. The patient ambulates with a walker. The request is to increase aide services to 10-12 hours a day, 7 days a week from 8 hours, 7 days a week, total 56 hours.

In part, the requested personal care services: 10 hours times 7 days a week for a total of 70 hours is medically necessary.

Appeal notes and assessments were reviewed. The patient is morbidly obese which limits her ability to complete basic activities of daily living (ADLs); this includes transition in and out of the bath for showering and personal hygiene as the patient wears diapers and has frequent urinary tract infections (UTIs) due to failure to change herself properly and timely. The request is for increased hours to help with dressing, bathing, grooming, meal prep, ambulating around the home and showering. The patient is diabetic and sometimes becomes hypoglycemic due to inability to eat in the evenings. Per documentation, the patient has declined cognitively in the last 2-3 weeks; decline is believed to be related to worsening dementia diagnosis. The patient is unable to recite an emergency plan. The patient needs assistance with weight bearing by 1 helper. The patient has been taking incorrect medications/doses. She is unable to ambulate with a walker now; is transferred to wheelchair and is pushed in and out of home. She fell 4 weeks ago in the doorway of her home. The patient can no longer feed herself and will not consume a meal unless fed. The patient now needs assistance with meal prep, housework, shopping, transferring on/off, chair/commode, incontinence care, dressing, feeding, and bathing. Durable medical equipment includes wheelchair and commode. Per assessment, the patient also has daily bladder incontinence and uses diapers, which have to be changed 3-4 times daily to prevent skin breakdown.
Per appeal letter, the patient needs:
--Toileting, transferring from bed to the chair
--Ambulating using the walker
--Meal preparation, feeding, prompting her to take her prepared medications
--Bathing dressing and grooming
--The patient lives alone and has no formal or informal support to provide her with the assistance to meet her personal needs on a regular basis.
Based on the above, personal care services: 10 hours times 7 days a week for a total of 70 hours is medically necessary.