Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, dementia, generalized muscle weakness, tremors, urinary incontinence, and malignant neoplasm of the skin.
Treatment: level 2 personal care services, per 15 minutes increase to 24 hours per day (live in).
The insurer denied coverage for level 2 personal care services, per 15 minutes increase to 24 hours per day (live in).
The denial is overturned.

This elderly female has significant functional impairment associated with several medical conditions. She needs assistance with all daily activities. The patient lives alone and receives personal care services, provided as Consumer Directed Personal Assistance Services (CDPAS). As per the recent Uniform Assessment System (UAS), the patient's son is the CDPAS aide. 

The functional status report indicates the patient was dependent on most activities except phone use (limited assistance). For Activities of Daily Living (ADLs), she needed maximal assistance for walking, and locomotion; extensive assistance for bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use; limited assistance for eating, and bed mobility. Compared UAS identifies a change in functional status for most ADLs: Bathing, dressing lower body: maximal assistance (extensive assistance); walking, locomotion: limited assistance (maximal assistance); toilet transfer, toilet use: limited assistance (extensive assistance); eating, bed mobility: set up help (limited assistance). Personal hygiene, dressing upper body: no change.

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions. Other factors include social and economic circumstances (e.g., caregiver support). Accelerated periods of decline can occur in response to new/acute medical events. As people age, functional reserve decreases; and when a new medical problem results in further functional decline, it becomes increasingly difficult to return to the prior level of function. 

The patient is dependent on caregivers for meal preparation/service. Whether she walks with maximal assistance or uses a wheelchair, she is unable to go to the kitchen unassisted and self-serve a pre-prepared meal. She also needs assistance with eating; so, a caregiver needs to be present for the entire meal. Older people who live alone are at risk for nutritional decline for various reasons (medical conditions, physical and/or cognitive impairment, social/economic factors). Older people are also at greater risk for dehydration. As per UAS, the patient takes a diuretic. Maintaining adequate fluid balance is a necessary aspect of the patient's medical care. It is medically necessary, and in the patient's best interest to have a caregiver present for all meals to help ensure adequate food and fluid intake.

As per the UAS, the CDPAS aide is needed to assist the patient with all mobility (transfers, walking, wheelchair); toileting/incontinence care; all meal preparation/service and assistance with eating; morning/evening ADLs (bathing, dressing, personal hygiene); repositioning; medications; all household tasks. The additional hours with live-in services are medically necessary to help prevent adverse health and safety events, e.g., skin damage and infection (incontinence, pressure); falls/injuries; to help ensure adequate nutrition and hydration, and assist with pain control when needed.

It is not clear from the available records whether live-in services will be provided as CDPAS or standard personal care aide (PCA) services. Recommendation for live-in services applies to CDPAS or PCA services.

Based on the above, the insurer's denial must be overturned. 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 level 2 personal care services, per 15 minutes increase to 24 hours per day (live in) services is substantiated.