Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Kidney failure, carpal tunnel syndrome, scoliosis, heart failure.
Treatment:  Personal Care Assistance Services, a total of 84 hours per week.

The insurer denied coverage for Personal Care Assistance Services, a total of 84 hours per week.  The denial is overturned.

This case involves a patient seeking authorization for coverage of personal care assistance services for total of 84 hours/week. The patient had extensive medical history which noted kidney failure, carpal tunnel syndrome, scoliosis, heart failure, inflammatory polyarthropathy, asthma, hypertension, reduced ejection fraction, atrial fibrillation, essential hypertension, pulmonary hypertension, cardiac amyloidosis, dysthymic disorder, and lymphedema. The patient was hospitalized. The patient had edema, a lung infection, and shortness of breath. The Uniform Assessment System reported that the patient lives alone and had been receiving personal care assistance services 7 days a week at 6 hours a day. The patient required assistance for activities of daily living including extensive assistance with walking, locomotion, toilet transfers/use, and bed mobility. An increase in 84 hours/week was requested.

Per the cited sources, patients who require uninterrupted care by more than 1 personal care aide for more than 16 hours in a calendar day may be appropriate for 24-hour split shift services when a personal care aide is unable to obtain 5 hours daily of uninterrupted sleep during the 8-hour sleep schedule. The use of personal assistance is crucial for patients with disabilities to allow them to remain in the community as opposed to being placed in institutional settings. In this case, the patient had extensive history with a recent COVID infection with deconditioning. She also had another exacerbation of her congestive heart failure which required additional diuretics and close monitoring. She required assistance with all activities of daily living. The documentation detailed a rapid decline in the patient's functional capabilities. She had decreased mobility, was unable to dress herself independently, and was often in soiled diapers for 18 hours a day. She was receiving palliative care and was in the process of enrolling in hospice care. The patient had become totally dependent. She was unable to stand, unable to self-transfer, or even sit herself up in bed. She was totally incontinent and unable to change her pamper herself. In the event of emergency, the patient could not leave the apartment.  The requested 84 hours/week is medically necessary for this patient. The patient is dependent on others for care. The patient will be unable to remain in the home without extensive assistance. The patient has had a significant decline and requires additional hours to meet basic needs that would otherwise be unavailable to her. The patient is also at risk for significant harm due to worsening functional capacity and confusion. As such, the denial of coverage for personal care assistance services, a total of 84 hours per week was not appropriate and is overturned.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for personal care assistance services, a total of 84 hours per week is overturned. Medical Necessity is substantiated.