Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's Disease, coronary heart disease and diabetes.
Treatment:  Increase in personal care services to 12 hours a day, 7 days a week.

The insurer denied coverage for increase in personal care services to 12 hours a day, 7 days a week.  The denial is overturned.

This elderly patient has an extensive medical history associated with functional impairment and needs assistance with daily activities. The patient lives alone. There is a friend who provides some informal help, but the patient primarily relies 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 56 hours per week (8 hours per day). The patient reported decline in mobility and increased difficulty with daily activities. The patient requested an increase of PCS to 84 hours per week (12 hours per day).

The most recent Uniform Assessment System (UAS) provided for review was done. Functional status report for IADL indicate patient needed maximal assistance for meal preparation, ordinary housework, shopping, stairs, transportation; extensive assistance for managing medications; limited assistance for managing finances; setup help for phone use. For ADL, the patient needed extensive assistance for bathing, upper/lower body dressing; limited assistance for personal hygiene, walking, locomotion, transfer toilet, toilet use; setup help for bed mobility, eating. 

The patient needs assistance with evening ADLs (personal hygiene, dressing, toileting). As per insurer's final denial letter, patient reported she needs help getting in and out of bed. The aide is needed to assist with ADLs at various times from morning until patient goes to bed. Splitting current PCS hours (8 hours per day) will leave extended time gap without assistance during the day. The patient is not required to change her mealtimes and bedtime based on PCS hours. Twelve hours is a reasonable timeframe for daytime activities and can provide the patient with help for all meals and ADLs during the day.

Managed Long Term Care policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service hours. It is medically necessary for the patient to have adequate caregiver assistance to ensure all daily activities are completed properly and safely; including all routine ADLs and IADLs; plus, ADLs that occur at unscheduled and recurring times of the day (e.g., toileting/incontinence care and mobility). Assistance is necessary to help prevent adverse health and safety events, e.g., falls/injury and household accidents, incontinence associated skin damage, weight loss/malnutrition. 

The patient will benefit from PCS 12 hours per day, as she needs assistance with all daily activities, including all ADLs from the time she gets up in the morning until she goes to bed in the evening, and assistance with all meals. There is no specific information available about the patient's nighttime ADL care needs (e.g., getting out of bed; toileting /incontinence care at night). However, the friend's letter indicated concern that the patient may need 24-hour care. The maximal number of hours that can be recommended for approval from this review is limited by the hours requested, as documented in the insurer's final adverse determination denial notice i.e., 84 hours per week. Re-assessment will determine if this plan is satisfactory or if further modification is needed.

Recommendation is given to approve Personal Care Services 12 hours per day, 7 days per week, total of 84 hours per week.

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 an increase in personal care services to 12 hours a day, 7 days a week is substantiated.