Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, dysphagia, hypertension, chronic obstructive pulmonary disease (COPD). 
Treatment: Personal care services (PCS) 24 hours a day, 7 days a week (split shift), totaling 168 hours. 
The insurer denied coverage for personal care services (PCS) 24 hours a day, 7 days a week (split shift), totaling 168. 
The denial is overturned.  

This case involves an elderly patient with a subject for review for the Denial of coverage for personal care services (PCS) 24 hours a day, 7 days a week (split shift), totaling 168 hours per week. 

A Uniform Assessment System was completed recently. According to the assessment, the member has moderate difficulty with hearing and severe difficulty with vision. She is totally dependent with meal preparation, ordinary housework, managing finances, phone use, shopping, transportation, bathing, personal hygiene, dressing the upper and lower body, locomotion, toilet use, and bed mobility. She also needs maximal assistance with managing medications. 

According to the Hours Evaluation for Paraprofessional Support (HELPS) Assessment Report the member required 63.5 hours per week of personal care services (PCS). 

The member was seen for a routine visit recently. She is alert and continuously confused and hard of hearing. Vitals are within normal limits. RN (registered nurse) reinforced teaching on safety measures, nutrition and hydration. 

According to a letter submitted, the patient is enrolled in a hospice and palliative care program for the diagnosis of Alzheimer's disease, dysphagia, hypertension, chronic obstructive pulmonary disease (COPD), and was hospitalized for pneumonitis. She has significantly declined and is now bed bound and she required total assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She is at an increased risk for pressure ulcers and requires repositioning every 2 hours as well as diaper changes. She also has agitation, hallucinations, and calling out at night. 

In an Appeal Letter submitted by the member's daughter, the member needs 24 hours around the clock care due to the member is bedridden, consistently and frequently incontinent, and she needs help with all facets of daily living, she is unable to feed herself, bathe, or communicate any of her needs. She is also on oxygen and needed a breathing treatment 4 times a day. 

She is not able to make her needs known, almost does not speak, and was not able to answer any questions during the assessment. She also does not recognize her family members. Unable to call 911/activate personal emergency response system (PERS) in case of emergency. Further, she  had a fall at home about recently, no injuries reported. The patient's daughters are her direct care and the daughter visits the member sometimes but she cannot do it on a regular basis. 

According to the assessment, the patient does not walk, she needs repositioning every 2 hours to prevent ulcers, completely incontinent, requires spoon feeding, and total assistance with dressing, meal preparation, housework, and shopping. Due to the cognitive impairment, limited range of motion (ROM), muscle weakness, fatigue, the member needs help with personal care/IADLs. 

Upon review of the medical information received, Uniform Assessment System - New York Community Health Assessment Comments Report, HELPS Assessment Report, Appeal Letters, Advocacy Report, Discharge Note and Case Information, she needs 24/7 care based on advanced age, dementia, and other severe comorbidities with severe limitations in functioning. 

Based on the above, the insurer's denial must be reversed. 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 personal care services (PCS) 24 hours a day, 7 days a week (split shift), totaling 168 hours per week is substantiated.