Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease

Treatment: Personal Care Services, 12 hours per day, 3 days a week for a total of 36 hours

The insurer denied coverage for Personal Care Services, 12 hours per day, 3 days a week for a total of 36 hours

The denial is upheld 

This is a patient with chronic medical problems that include congestive heart failure, chronic obstructive pulmonary disease (COPD) and uses portable oxygen. The patient lives alone in a 1-bedroom apartment. The insurer approved Personal Care Services (PCS) 8 hours/day, 7 days/week. The patient requested an increase in PCS from 8 hours per day, 3 days a week for a total of 24 hours to 12 hours per day, 3 days a week for a total of 36 hours; denied by the insurer and leading to an external review.

The Uniform Assessment System (UAS) report notes that the patient's cognitive skills are described as minimally impaired. The patient is "able to activate Personal Emergency Response System (PERS) in case of emergency." The patient's ability to complete much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping; reportedly varies from total dependence to extensive assistance. The patient reportedly requires maximal assistance for bathing, lower body dressing and toilet use. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, eating, bed mobility, locomotion, toile transfer and ambulation. The patient is reportedly frequently incontinent of bladder and continent of bowel. There have been no reported falls over the prior 3 months. 

The clinical records do not support the patient's condition and functional deficits at a level or unpredictable as to require the requested PCS 12 hours per day, 3 days a week for a total of 36 hours. This physician would agree that the patient may benefit from monitoring for safety; particularly due to his reported weakness and falls risk. However, PCS for companion care or safety supervision without the direct provision of activities of daily living (ADL) task assistance is not a covered service. The patient's daughter indicates the patient needs assistance during the evenings. This physician also agrees with the insurer: "The plan suggests splitting your approved aide schedule into 2 shifts to best meet your morning and evening needs. The morning aide can help you with personal care, prepare your meals, assist you with your daily activities, toileting and make sure that you are safe before leaving. The aide will help you again upon return to your home and prepare you for bed before leaving." Based on the records reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved PCS 8 hours/day 7 days/week for a total of 56 hours/day, which includes the 8 hours per day, 3 days a week for a total of 24 hours.

From a physical medicine and rehabilitation perspective, overturning Personal Care Services, 12 hours per day, 3 days a week for a total of 36 hours is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in Personal Care Services, 12 hours per day, 3 days a week for a total of 36 hours is not substantiated.