Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, diabetes, hypertension
Treatment: Personal care services (PCS) hours 12 hours a day, 7 days a week (w/o (without) Schedule)
The insurer denied coverage for personal care services hours 12 hours a day, 7 days a week (w/o Schedule)
The denial is overturned.
 
This elderly patient has functional impairment associated with several medical conditions and needs assistance with all daily activities. He lives alone. One informal helper is identified in the Uniform Assessment System (UAS), but it appears the patient primarily depends on personal care services (PCS) for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient has been receiving PCS 48 hours per week. The UAS indicates the patient was hospitalized recently due to back pain. The final denial letter indicates the patient's daughter reported the patient's condition changed after hospitalization. The daughter (patient designee) requested an increase of PCS to 84 hours per week (12 hours per day), which was denied. 

The most recent UAS provided for review was reviewed. The functional status report for IADLs indicated the patient is totally dependent for ordinary housework; he needs maximal assistance for all other IADLs. For ADLs, the patient needs maximal assistance for bathing, dressing lower body, walking, locomotion, transfer toilet; extensive assistance for personal hygiene, dressing upper body, toilet use, bed mobility; and limited assistance for eating. No other UAS was provided for review, but it was noted there was a decline in ADL status compared to 90 days ago, or since the last assessment if less than 90 days. Self-sufficiency was reported as deteriorated compared to 90 days ago, or since last assessment if less than 90 days.

The patient needs substantial assistance with medications due to several factors, including cognitive impairment, impaired vision, and possibly tremor. This creates a problem with pain management. The patient uses a Lidoderm patch daily; but voltaren gel and Tylenol are used prn (as needed). With current PCS hours, the patient has no safe, effective method for pain control during the hours the aide is not present (17-18 hours per day). The patient needs extensive assistance with bed mobility, and he has chronic back pain, which can cause greater difficulty moving in bed. Without a caregiver to assist, the patient may not even be able relieve pain by repositioning himself. This does not appear to be an acceptable pain management plan. When a person with chronic pain is unable to provide adequate self-care to relieve pain, then a caregiver needs to be part of the pain management plan.

Considering the patient's medical history and functional status as noted in the available records, it is medically necessary, and in the patient's best interest, to have a caregiver present throughout the day to assist with daily activities. The patient needs assistance for all IADLs and ADLs. This includes housework; preparation/service of all 3 meals and assistance with eating; assist with medications (routine and prn); routine morning and evening ADLs (bathing, dressing, personal hygiene); and unscheduled/recurring activities, including toileting, incontinence care, transfers, walking, bed mobility. Without adequate assistance, the patient is at risk for adverse health and safety events, e.g., nutritional decline, dehydration, hypoglycemia, aspiration, skin damage, falls/injuries, inadequate pain control.

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 increase in personal care services hours to 12 hours a day, 7 days a week (w/o Schedule) is substantiated.