Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Myotonic dystrophy, respiratory failure on a mechanical ventilator, thyroid papillary carcinoma status post thyroidectomy, hypothyroidism, status post cataract surgery, ptosis, ophthalmoparesis, hearing loss, adrenal insufficiency, pneumonia, anxiety, and depression.
Treatment:  Personal Care Services 8 Hours a Day, 7 Days A Week.

The insurer denied Personal Care Services 8 Hours a Day, 7 Days A Week.  The denial is overturned.

The patient is an adult male with a history of general debility due to myotonic muscular dystrophy with quadriparesis and respiratory failure requiring mechanical ventilation. The patient receives Private Duty Nursing (PDN) 168 hours per week (24-hour split-shift per day, 7 days per week) based on UAS (Uniform Assessment System) evaluation of 7 months ago. The request is for Personal Care Assistance through Home Health care to be added to existing to the private duty nursing, 56 hours per week (8 hours per day, 7 days per week), based on UAS (Uniform Assessment System) evaluation of last month. The health plan denied coverage of the request, because the patient has a supporting spouse, and the current hours through the PDN (private duty nursing) provide enough time for personal care needs, including bathing, eating, meal preparation, medication reminders, all laundry, shopping, dressing, personal hygiene, and toileting. The additional hours requested are because of the patient's chronic medical conditions, and to help with her Activities of Daily Living (ADLs), as he requires extensive assistance with dressing, bathing, grooming, transferring, turning, positioning, toileting, ambulation, meal preparation, eating, housekeeping and shopping, etc. In addition, he needs assistance with items in his home to assist with safety in use including a Hoyer lift, hospital bed, pressure air mattresses, and oxygen, and services through the PDN (private duty nursing) are not adequate to meet these extra needs. A review of the records showed that the patient has multiple chronic medical conditions, 
including myotonic dystrophy, respiratory failure on a mechanical ventilator, thyroid papillary carcinoma status post thyroidectomy, hypothyroidism, status post cataract surgery, ptosis, ophthalmoparesis, on G-tube feeding, hearing loss, adrenal insufficiency, pneumonia, anxiety, and depression. UAS (Uniform Assessment System) evaluation of last month showed that the patient was bed-bound and totally dependent on all ADLs (activities of daily living). The patient lives in a three-bedroom apartment with his wife and one of his twin sons. The patient is bed-bound.

The requested Personal Care Services 8 Hours a Day, 7 Days A Week are medically necessary.

The patient is bed-bound and totally dependent on all ADLs (activities of daily living). The PDN (private duty nursing) service is mostly nursing care that includes tube feeding and mechanical ventilator management. The reason for denial by the health plan as noted in the clinical information above, does not align with the patient's disability features as noted in the UAS (uniform assessment system) evaluation of last month, as stated above.
Therefore, the requested personal care service 56 hours per week (8 hours per day, 7 days per week) is medically necessary.