Appeal type: Medical necessity
Decision: Upheld

Diagnosis: coronary artery disease (CAD), sick sinus syndrome, paroxysmal atrial fibrillation, hypertension

Treatment: in Personal Care Services (PCS) hours to 24 hours a day - 7 days a week (split shift)

The insurer denied coverage for in Personal Care Services (PCS) hours to 24 hours a day - 7 days a week (split shift)

The denial is upheld

This is an elderly male who lives alone. He is diagnosed with a history of coronary artery disease (CAD), sick sinus syndrome, paroxysmal atrial fibrillation, hypertension, hyperlipidemia, benign prostatic hyperplasia (BPH), cerebral vascular accident (CVA) with right residual weakness, chronic back pain with multiple spine compressions with unsteady gait, and the patient has new behavioral changes concerning for delirium superimposed on dementia. Based on the assessment, the participant needs help with housekeeping, shopping, laundry, bathing, toileting, dressing, walking and personal hygiene. The participant uses a walker and a wheelchair to help move around his environment. He was discharged from nursing rehabilitation recently and progressed to walk 60 feet using a walker with help. The participant does not have incontinence; however, he sometimes does not make it to the toilet for bowel and bladder management. The Plan provides incontinence supplies, he has a bedside commode and urinal for nighttime toileting. The Plan provides recommended services for occupational and physical therapy (OT/PT) for strengthening and gait training; and a hospital bed with a pressure relieving mattress. Based on the assessment tool the participant's needs totaled 51.5 hours, 7 days week of assisted care needs.  

A letter of medical necessity submitted by the patient's medical provider, detailed that the 
patient is diagnosed with a history of Coronary artery disease (CAD), sick sinus syndrome, paroxysmal atrial fibrillation, hypertension, hyperlipidemia, benign prostatic hyperplasia (BPH), cerebral vascular accident (CVA) with right residual weakness, chronic back pain with multiple spine compressions with unsteady gait, and the patient has new behavioral changes concerning for delirium superimposed on dementia. It was also noted that the patient lives alone and would benefit from additional hours. 

A letter of support submitted by a representative for the patient noted that the patient's medical history shows continued physical and mental deterioration, and an inability to independently manage his daily activities, such as frequent toileting episodes and  repositioning to avoid further instances of pressure ulcers. He requires repositioning at least every 2-4 hours, coupled with incontinence episodes, he has several activities of daily living (ADL) needs throughout the night. Due to his comorbidities, it is unsafe for the participant to attempt activities of daily living (ADLs) independently as this could result in additional falls and continued physical decline. 

The Plan provides incontinent supplies, a bedside commode and urinal for nighttime toileting.  The Plan has also recommended services for occupational and physical therapy (OT/PT) for strengthening and gait training and a hospital bed for with a pressure relieving mattress. With the supportive services recommended by the service plan, the approved 12 hours a day, 7 days a week for a total of 84 hours per week, can sufficiently support the assisted care needs to maintain patient safety within the home and community.

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 increase in Personal Care Services (PCS) hours to 24 hours a day, 7 days a week (split shift) services is not substantiated.