Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, atrial fibrillation and dementia. 
Treatment: Level 2 Personal Care Services (PCS), per 15 minutes increase to 24 hours per day (split shift). 

The insurer denied coverage for level 2 Personal Care Services (PCS), per 15 minutes increase to 24 hours per day (split shift). 

The denial is overturned. 

This patient elderly with chronic medical problems including congestive heart failure, atrial fibrillation and dementia.  According to the submitted clinical records, he has been in a skilled nursing facility with an anticipated discharge to home.  He is currently approved by the insurer for PCS 24 hours live-in and is requesting level 2 Personal Care Services (PCS), per 15 minutes increase to 24 hours per day (split shift); which is currently under review. 

According to the Uniform Assessment System (UAS) report, the patient cognition is described as "moderately impaired. - Decisions consistently poor or unsafe; cues/supervision required at all times."  He is totally dependent for activities of daily living (ADL) including bathing, personal hygiene, lower body dressing, and toilet use.  He is bowel and bladder incontinent.  Maximal assistance is required for upper body dressing and bed mobility.  The patient is transferred to a wheelchair via a Hoyer lift in the skilled nursing facility (SNF).  He is on "aspiration precaution when feeding as has to be fed by care takers."  The occupational and physical therapy notes from the SNF corroborate his total dependence for activities of daily living (ADL) and mobility. 

The patient has severe cognitive and functional impairments that have reportedly declined over the past several months after being hospitalized and in the SNF.  His condition and functional needs are at a level or unpredictable as to require the requested level 2 Personal Care Services (PCS), per 15 minutes increase to 24 hours per day (split shift).  Of particular concern is his total dependence for bed mobility, complete bowel/bladder incontinence, need for intermittent bed repositioning and risk of developing pressure ulcers. The patient health and safety can be appropriately provided and maintained at home with the requested level 2 Personal Care Services (PCS), per 15 minutes increase to 24 hours per day (split shift). 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, the requested level 2 Personal Care Services (PCS), per 15 minutes increase to 24 hours per day (split shift)  is medically necessary. 

The insurer's denial of coverage for the level 2 Personal Care Services (PCS), per 15 minutes increase to 24 hours per day (split shift) is overturned. Medical Necessity is substantiated.