Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, end stage kidney failure, osteoarthritis
Treatment: Personal Care Services Seven Days per Week, Live-in
The insurer denied: Personal Care Services Seven Days per Week, Live-in
The denial is overturned

This elderly male patient has conditions including diabetes, end stage kidney failure on hemodialysis, hypertension, coronary artery disease, chronic pain, and osteoarthritis.  He lives alone.  He is appealing denial of personal care services for seven days per week, live-in.  The health plan is reducing hours to 56 hours per week.  Uniform Assess System (UAS) evaluation completed recently shows modified independent cognition and functional status, maximal assistance with housework, meal preparation, shopping, and transportation; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, and tolerating; and limited assistance with managing finances and medications, phone use, bed mobility, and eating.  He uses a rollator for indoor ambulation and a wheelchair for outdoors.  He does not have bowel or bladder incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been no decline in level of functioning.  

Appeal statements note the patient requires more assistance after dialysis due to increased weakness and fatigue after dialysis and has experienced a medical emergency at night due to complications of his dialysis catheter.  He is a fall risk.  He needs monitoring for sores and infection.  He needs continuous hands-on care to keep him in his home.  He has a history of recurrent hypoglycemia due to forgetting to eat.  The appeal notes the patient's conditions has been managed with live-in care.

The proposed treatment, personal care services seven days 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 activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding. 

This patient, with multiple chronic conditions, is appealing denial of personal care services for seven days per week, live-in.  The health plan is reducing hours to 56 hours per week.  Uniform Assess System (UAS) evaluation completed recently shows the patient requires assistance with all activities of daily living (ADLs).  Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been no decline in level of functioning.  There are several appeal statements supporting the patient's needs for live-in personal care services.  Statements indicate the patient needs daytime and nighttime care due to complications of his chronic medical conditions.  The patient has been able to stay in his home with live-in care.  This patient's physical functioning is significantly impaired. There has been no improvement in his level of functioning between Uniform Assessment System (UAS) evaluations performed in last year and this year.  The information provided does not support the plan's proposed decrease in personal care services to 56 hours per week.  The need for assistance with all activities of daily living (ADLs) cannot be met with personal care services to 56 hours per week.  The requested maintenance of personal care services for seven days per week, live-in is medically necessary and appropriate to meet this patient's needs.