Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple medical conditions.
Treatment: Increase Personal Care Services Level II To 24 Hours per Day, Seven Days Per Week (Live-In).

The insurer denied the Increase Personal Care Services Level II To 24 Hours per Day, Seven Days Per Week (Live-In).  The denial is overturned.

The patient is an elderly female. Her medical conditions including Insomnia; Dizziness; Coronary heart disease; Emphysema; Congestive heart failure; Anxiety; Depression; Acid reflux; Constipation; High blood pressure; Dry eye syndrome; Gout; Osteoarthritis; Asthma; Glaucoma; Angina; Age-related cognitive decline; Bronchiectasis; Acquired absence of part of lung, unspecified and a History of COVID. She was admitted after a fall and reports multiple falls. The patient has been in a Skilled Nursing Facility (SNF). She lives alone. Denial of increase personal care services to 24 hours per day, seven days per week (live-in) is being appealed. The health plan approved 8 hours per day, 7days per week, for a total of 56 hours per week.

Uniform Assessment System (UAS) evaluation completed recently shows modified independent cognition and functional status: total dependence with meal preparation and housework; maximal assistance with shopping, transportation, bathing, and lower body dressing; extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toileting, and bed mobility; limited assistance with managing finances; and supervision with eating. The patient has frequent bladder incontinence. Her DME (durable medical equipment) includes wheelchair, cane, walker, grab bars, shower chair, incontinent supplies, commode, and PERS (personal emergency response system). Compared to UAS (Uniform Assessment System) evaluation completed 5 months earlier, there has been a decline in functioning with bathing. A letter from the patient's provider notes the patient has multiple conditions. She has an unsteady 
gait. She requires full-time live-in assistance for assistance with ADLs (activities of daily living) and supervision. A statement is provided that the patient has fallen 9 times and was in a nursing home for 3 months.  She had a fall when trying to get off the toilet. It notes that she cannot do anything by herself.

The requested Increase Personal Care Services Level II To 24 Hours per Day, Seven Days Per Week (Live-In) 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 (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase personal care services to 24 hours per day, seven days per week (live-in) is being appealed. The health plan approved 8 hours per day, 7 days per week, for a total of 56 hours per week. The patient has multiple chronic conditions and has a history of numerous falls with recent skilled nursing stay after a fall. Uniform Assessment System (UAS) evaluation completed recently shows she requires assistance with all ADLs (activities of daily living), except for eating. She has bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed on 5 months earlier, there has been a decline in functioning with bathing. The appeal statements support the 
need for assistance with ADLs (activities of daily living) as noted above. This patient's physical functioning is significantly impaired. The need for assistance with all ADLs (activities of daily living) cannot be met with the approved personal care services 56 hours per week. The approved hours are insufficient to meet the patient's needs. The requested increase in personal care services to 24 hours per day, seven days per week (live-in) is medically necessary and appropriate.