Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, heart failure, arthritis, and glaucoma
Treatment: Personal Care Service to 24 Hours a Day, Live-in 
(13 Hours a Day), 7 Days a Week, for a Total of 91 Hours per Week
The insurer denied: Personal Care Service to 24 Hours a Day, Live-in 
(13 Hours a Day), 7 Days a Week, for a Total of 91 Hours per Week
The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, heart failure, arthritis, and glaucoma. She was discharged from a SNF (skilled nursing facility) last month. 
Denial of personal care service to 24 hours a day, live-in (13 hours a day), 7 days a week, for a total of 91 hours per week is being appealed. The health plan approved 56 hours per week. The health plan notes that the current hours can be split to meet morning and evening needs. The plan does not provide care for safety supervision and companionship. The patient's Uniform Assessment System (UAS) evaluation completed last month shows minimally impaired cognition and functional status: total dependence with housework, and walking; maximal assistance with managing finances, shopping, bathing, lower body dressing, locomotion, and toileting; and extensive assistance managing medications, personal hygiene, upper body dressing, bed mobility, and eating. She is wheelchair bound. She is incontinent of bowel and bladder.
A letter from the patient's provider notes the patient has several chronic conditions and is wheelchair dependent. She had falls resulting in an ankle fracture 5 years ago and femur fracture 2 years ago. She has a rectal wound. The provider recommends 24-hour care to ensure safety. The patient is not able to answer the door. She is unable to get out of the bed, toilet, and perform personal hygiene without assistance. She is unable to cook. She cannot communicate properly due to dementia.
A letter from the patient's daughter notes she is the primary caregiver and lives out of state. The patient needs assistance with ADLs (activities of daily living). She cannot get out of bed or get to the bathroom without assistance. She cannot prepare meals.

The Personal Care Service to 24 Hours a Day, Live-in (13 Hours a Day), 7 Days a Week, for a Total of 91 Hours per Week is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs including toileting, walking, transfers, turning/positioning, or feeding. Denial of personal care service to 24 hours a day, live-in (13 hours a day), 7 days a week, for a total of 91 hours per week is being appealed. The health plan approved 56 hours per week.
This patient has multiple chronic conditions, including recent SNF stay. The health plan notes that the current hours can be split to meet morning and evening needs. The plan does not provide care for safety supervision and 
companionship. Uniform Assessment System (UAS) evaluation completed last month shows the patient requires extensive assistance to total dependence with all ADLs. Appeal statements support that the patient is wheelchair bound needs assistance with all ADLs. She lives alone. She has a history of falls that have resulted in leg fractures. She does not have informal support. She is unable to transfer and ambulate without assistance. Due to the patient's inability to ambulate and transfer without assistance, the approved personal care services of 56 hours per week insufficient to meet the patient's needs for assistance. 
Splitting these hours would leave the patient immobile. The requested personal care service to 24 hours a day, live-in (13 hours a day), 7 days a week, for a total of 91 hours per week is medically necessary.