Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Decubitus Ulcer

Treatment: Increase in personal care services from 24 hours a day, 7 days a week (live-in) for a total of 91 hours a week, to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week.

The insurer denied the increase in personal care services from 24 hours a day, 7 days a week (live-in) for a total of 91 hours a week, to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week.

The denial was overturned.

This is a female patient has been hospitalized twice in the past few months and returned home with substantial decline in functional status and requiring high level of assistance with personal care and household related activities. She has a history of dementia and pressure ulcers. She also requires skilled services resulting from changes in her medical condition. It appears the patient is totally dependent on caregiver support for all daily activities. When the patient returned home after a hospitalization, she was approved for personal care services (PCS) 24 hours live-in services (patient was receiving live-in services prior to hospitalization). 

The patient has dementia. It appears this was the primary cause of her functional impairment before the recent acute illnesses. As per the Uniform Assessment System (UAS), the patient was ambulatory with assistance, and appears to have had some limited speech. Cognition was noted as moderately impaired decision making, and substantial memory problems. Based on the hospital discharge summary, the patient was critically ill during that hospital admission with septic shock; she responded to treatment and was stabilized. Following this acute illness, it appears patient had very limited mobility and was non-verbal. It is reported that she is bedbound, and incontinent of bladder and bowel. PEG was placed in the hospital for nutrition. 

Pressure ulcers can have severe consequences, and for elderly patients who often have multiple co-existing conditions, pressure ulcers present complex management issues including treatment (wound care, pressure relief, incontinence care, nutrition, pain management), healing potential (affected by other conditions such as DM, PVD), medical complications (infection, possible surgical intervention), homecare responsibilities (informal caregivers, personal care services, skilled nursing services). For this patient, she has already had extensive damage, with infection extending to bone. The patient has a PEG, so nutritional support can be provided.  It is not clear how wound care is being provided. Visiting nurse may be providing dressing changes, but often it is necessary for a caregiver in the patient's home to learn how to apply dressings, so if the dressing is soiled or comes off between scheduled dressing changes, some type of clean dressing can be applied. Wound care is generally beyond the scope of care for personal care aides, and so informal caregivers may be involved in this aspect of care. One of the challenges with pressure ulcers on the sacrum/buttock area is keeping the ulcer and dressing clean when the patient is incontinent. Contamination of the ulcer from urinary and fecal incontinence can delay wound healing, cause infection, and can cause further skin damage around the ulcer from chronic moisture; and so frequent and proper incontinence care is an essential aspect of pressure ulcer care.

Personal Care Services 24 hours per day, 7 days per week (split shift); total of 168 hours per week was medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for an increase in personal care services from 24 hours a day, 7 days a week (live-in) for a total of 91 hours a week, to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week is overturned.