Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Lewy Body Dementia

Treatment: Personal Care Services, Level 2, 12 hours per day, 7 days per week, total of 84 hours per week

The insurer denied coverage for Personal Care Services, Level 2, 12 hours per day, 7 days per week, total of 84 hours per week.

The denial is modified.

 
This is a patient with chronic medical problems including Lewy Body dementia.  The insurer approved Personal Care Services (PCS) 5 hours/day, 7 days/week for a total of 35 hours/week.  The patient is seeking Personal Care Services, Level 2, 12 hours per day, 7 days per week, total of 84 hours per week.

The Uniform Assessment System (UAS) report is dated 3/12/23.  The patient's cognitive skills are described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times."  Care is directed by the patient's elderly spouse who also has multiple medical problems.  The patient is reportedly total dependent to maximal assistance for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance with bathing, personal hygiene, dressing and toilet use.   Limited assistance is reportedly needed for toilet transfer, locomotion and ambulation.  The patient is at the supervision level or independent for eating and bed mobility.  The patient is reportedly occasionally incontinent of bladder and continent of bowel.  

The patient's functional ability has declined when compared to the previous UAS.  
However, the patient's condition and functional deficits are not at a level or unpredictable as to require the requested PCS 12 hours/day, 7 days/week for a total of 84 hours/day.   This physician would agree the patient may benefit from monitoring for safety, particularly due to reported progressive cognitive deficits and weakness.  However, PCS for companion care or safety supervision without the direct provision of activities of daily living (ADL) task assistance is not a covered service.  This physician does note the progressive nature of the patient's underlying clinical condition and declining functional ability as noted by comparing the UAS reports.  As such and based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by increasing PCS 8 hours/day, 7 days/week for a total of 56 hours/week.    

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based.
   
From a physical medicine and rehabilitation perspective, the requested Personal Care Services, Level 2, 12 hours per day, 7 days per week, total of 84 hours per week is not medically necessary.  PCS level 2, 8 hours per day, 7 days per week for a total of 56 hours per week is medically necessary.   

Based on the above, the insurer's denial must be modified. 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, Level 2, 12 hours per day, 7 days per week, total of 84 hours per week services is not substantiated.  However, PCS level 2, 8 hours per day, 7 days per week for a total of 56 hours per week is medically necessary.