Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD (chronic obstructive pulmonary disease), anxiety, depression, CAD (coronary artery disease), HTN (hypertension) and DM (diabetes mellitus)
Treatment: Increase Personal Care Services to 12-24 Hours Live in x 7 Days Per Week
The insurer denied the Increase Personal Care Services to 12-24 Hours Live in x 7 Days Per Week.
The denial is upheld. 

The patient is a female with diagnoses including COPD (chronic obstructive pulmonary disease), anxiety, depression, CAD (coronary artery disease), HTN (hypertension) and DM (diabetes mellitus). The patient lives alone and currently receives services for 8 hours x 5 days and 6 hours x 2 days per week. The patient is appealing denial of 12-24 hours live-in for 7 days per week.

The patient reports having been hospitalized and having experienced decline in cognitive and functional status since hospitalization. Assessment performed shows minimally impaired cognition and functional status: total dependence with housework; max assistance with meal preparation, shopping, bathing, and LB (lower body) dressing; extensive assistance with managing finances and medications, personal hygiene, UB (upper body) dressing, walking, locomotion, and toileting; and limited assistance with phone use, bed mobility, and eating. She wears pull-ups due to incontinence of bowel and bladder. The patient has the following equipment: PERS (personal emergency response system), walker and shower chair. Bedside commode and PT (physical therapy) are available through her plan.

The PCA (personal care assistant) reports that the patient ambulates with unsteady gait with a walker for short distance. She is unable to tolerate long periods of standing. She requires hands-on assistance from sitting to standing due to weakness.

The statement from the provider states that the patient does not want nursing home placement. It further states that increasing the home attendant services will give the patient the physical support she needs and may improve her mental health.

No, the Increase Personal Care Services to 12-24 Hours Live in x 7 Days Per Week is not medically necessary.

Medically necessary services are those which are 

1) Safe 2) Effective 3) Generally accepted national standard of medical practice 4) Not provided primarily for convenience of the patient or the practitioner 5) The least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is not medically necessary because it is not consistent with generally accepted national standard of medical practice for this patient.

This patient was approved for PCS (personal care service) hours at 8 hours x 5 days and 6 hours x 2 days per week based on assessment performed. The provider is requesting additional support to assist with physical needs as already accounted for in another assessment. The patient had been hospitalized for approximately one week prior to the assessment and noted a decline in strength since hospitalization. The assessment shows the patient needs assistance with housework, meal preparation, shopping, bathing, dressing, managing finances and medications, personal hygiene, walking, locomotion, toileting, phone use, bed mobility, and eating. The patient has a walker and shower chair. She is eligible for a bedside commode as well as PT (physical therapy). The assessment does not support the medical necessity for PCS (personal care service) services at 12-24 hours live in x 7 days per week. PCS (personal care service) is not indicated when there are no tasks being performed. This patient has limitations primarily due to weakness and poor endurance. Standard of care would include PT (physical therapy) to improve strength and mobility in a patient such as this. The approved 8 hours x 5 days and 6 hours x 2 days per week is appropriate to meet the patient's needs with ADLs (activities of daily living) and personal care.