Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End Stage Renal Disease

Treatment: Personal Care Services, Level 2

The insurer denied the personal care services Level 2. The denial was reversed. 

This is a male patient with a history of end stage renal disease who has received hemodialysis for one year three times a week. He has an arteriovenous (AV) fistula in his left arm. It was reported that the patient experiences weakness after his dialysis treatments. He requires some assistance with his activities of daily living (ADLs) due to lower back pain, impaired balance and fatigue. The patient has limited restrictions due to the AV fistula in his left arm. A request for personal care services level 2; 16 hours a week was made.
Patients receiving long term hemodialysis often experience symptoms that affect their functional capacity. The need for some assistance with daily activities may be due to pain, weakness, fatigue, impaired balance. In addition, precautions are needed to protect the A-V fistula. Various strenuous tasks using the arm with the fistula can be harmful to the maintenance of the fistula (e.g. avoid heavy lifting or carrying heavy objects over fistula). It is not unusual for patients on dialysis to need assistance with ADLs and IADLs.

The patient has a slow, unsteady gait, needs frequent rest periods when walking, and has difficulty standing up. He reports lower back pain which likely contributes to difficulty with ambulation and transfers. The patient reports increased weakness after dialysis. Weakness and fatigue are common symptoms for patients receiving dialysis long term. The symptoms are due to multiple factors such as anemia, inflammation, uremia, stress, physical inactivity, post-dialysis fatigue. These symptoms and functional limitations result in greater degree of difficulty performing daily tasks. The UAS indicates the patient needs extensive assistance with meal preparation, housekeeping and shopping; which is consistent with his symptoms of weakness, fatigue, back pain, and the need to avoid stressful, weight-bearing activities with his left arm. It is reported in the UAS that patient is independent with ADLs except for setup help. Nursing comments noted that patient needs assistance transferring in and out of the tub. Setup help can relieve some of the burden of performing daily tasks, especially when weakness and fatigue become more debilitating. It is also possible that when patient's symptoms are worse, some degree of assistance (in addition to setup help) is needed.

As a result of the patient's symptoms and functional limitations associated with end stage renal disease and dialysis, caregiver assistance with daily activities (IADLs and ADLS) is medically necessary. As per the UAS, the patient lives alone. The only informal caregiver identified in the UAS is a brother who provides some assistance with IADLs; but the frequency of assistance and specific tasks provided are not noted (there was no informal help within the previous 3 days of the UAS). It is reasonable to conclude that if the patient had adequate, consistent help with daily activities from informal caregivers, he would not need to apply for personal care services.

As a result of his functional impairment associated with long term hemodialysis, the patient can benefit from assistance with daily activities. Without informal caregivers who can provide assistance on a consistent basis, then personal care services are medically necessary. 

Personal Care Services, level 2, 16 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier denial of coverage for the requested Personal Care Services, Level 2 is reversed. The medical necessity is substantiated.