Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Vascular Accident, Glaucoma

Treatment: Personal Care Services (PCS) 24 hours a day, 7 days a week (split-shift)
The insurer is denied coverage for Personal Care Services (PCS) 24 hours a day, 7 days a week (split-shift)
The denial is overturned. 
This is a female with past medical history (PMH): recurrent cerebral vascular accident (CVA), osteoarthritis, multiple falls, status post (s/p) left femoral fracture open reduction internal fixation (ORIF), glaucoma and is legally blind in her right eye and obesity. She is dependent in ADLs and IADLs due to worsening of physical and cognitive problems. She has right-sided weakness from stroke. Patient needs assistance to walk a short distance to a commode, and with transfers in and out of bed; she is high risk for falls. Bathing and toileting are especially difficult. She is bed and wheelchair bound. She has severe urinary incontinence and has newly developed pressure sore and fungal rash. She requires turning and positioning every 2 hours. Her cognitive function has declined and she experiences sundowning, anxiety and confusion. The patient needs home care 24 hours a day for ADLs and IADLs.

There are several medical conditions that contribute to the patient's limited functional ability. Documentation from early 2020 indicated patient needed considerable assistance for most daily activities at that time, so her current situation is not completely due to the hip fracture. However, as often occurs with elderly people, when a person's baseline function is impaired, an acute medical event can precipitate a significant decline in health and function. 

The patient has extensive cerebrovascular disease including h/o CVA. She has residual right sided weakness. Her cognitive impairment may also be due to recurrent strokes (vascular dementia). The UAS indicates cognitive impairment has worsened, as her decision making capacity declined since last assessment. She is unable to use a PERS, which she could use in the past. 

The diagnosis of osteoarthritis is noted in the UA and that she has no pain; but the medication list includes Lidoderm patch daily and prn voltaren gel and acetaminophen. The patient may not have had pain at the time of the UAS, but it appears that chronic pain is part of her medical history, and may have a new source of pain related to recent hip fracture. 

The UAS indicates patient has dyspnea with normal daily activities. The cause is not identified, but the UAS indicates patient returned to the hospital (after hip surgery) due to difficulty breathing. Details are not available other than a note in the UAS reporting patient had fluid on her lungs and was discharged with home oxygen.  Dyspnea is a debilitating symptom, and increases the burden of performing daily activities. It is also noted the patient has severe fatigue to the point where she is unable to start normal daily activities. Fatigue can be a cumulative effect of various medical conditions, and can severely limit a person's capacity to participate in most daily activities.

Personal Care Services 24 hours per day, 7 days per week (split shift); total of 168 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Services (PCS) 24 hours a day, 7 days a week (split-shift), is substantiated. The insurer's denial is overturned.