Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immune disorder, type 2 diabetes mellitus, chronic kidney disease, depression, neuropathy, benign prostatic hyperplasia, gastroesophageal reflux disease and schizophrenia

Treatment: continued long-term custodial care

The insurer is denied coverage for continued long-term custodial care.

The denial is overturned. 

This case involves a patient who has a prior medical history that includes diabetes status post neuropathy, chronic kidney disease, depression, immune disorder, and schizophrenia.  The documentation indicated he has been a long-term care resident for years.  He was seen pertaining to wounds located on the left dorsal foot as well as left leg, right posterior leg, right foot, left and right thigh, and left posterior leg.  The documentation indicated there has been no change since prior visit.  The patient did undergo muscle tissue debridement and a total area of 12 cm2 [centimeters] of devitalized tissue was debrided.  The documentation indicated that other wounds were also assessed and treated.  The discharge summary from Occupational Therapy indicated the patient will improve ability to safely and efficiently perform activities of daily living (ADL) such as brushing his teeth and washing his face.  Documentation does indicate he is alert and oriented to person, place, and time according to further documentation and appeared to be in good spirits without complaints of pain.  He needed extensive help with transfers and limited help with bed mobility.  The documentation does indicate he is incontinent of both bowel and bladder and continued to remain on Bactrim for prophylaxis.  The documentation indicated continued care was needed.  He was evaluated for a follow-up regarding behavior disturbances.  He was being seen after the nursing staff reported he has been having more angry outbursts and refusing care.  The physician did indicate within the interview the patient did seem more withdrawn and paranoid.  The documentation detailed he was not on any type of neuropsychiatric medications and therefore it was recommended at this time that he undergo a psychiatry consultation. The most recent document indicated the patient had a behavioral disturbances the night prior he had called 911 indicating he had an episode of emesis and was not feeling well.  The patient was evaluated in the emergency department and sent back to the facility without intervention.  It was recommended he undergo psychology consultation.

Based on the medical documentation, the patient has a history of diabetes status post neuropathy, chronic kidney disease, depression, human immunodeficiency virus/acquired immune deficiency syndrome, and schizophrenia. He is noted to have poor insight and judgement, with agitation, insomnia and paranoid delusions. Because of the continued behavioral disturbances, the continued long-term custodial care is considered medically necessary. Additionally, he has bilateral weakness for which he requires continued assistance with performance of activities of daily living (ADLs), due to his functional deficits.

The condition has not changed the health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for continued long-term custodial care is overturned. Medical Necessity is substantiated.