Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Diabetes, Cerebrovascular Accident

Treatment: Personal care services (PCS) 22 hours a day, 5 days a week, 23.5 hours a day, 1 day a week, and 23 hours a day, 1 day a week for a total of 156.5 hours a week

The insurer denied coverage for personal care services (PCS) 22 hours a day, 5 days a week, 23.5 hours a day, 1 day a week, and 23 hours a day, 1 day a week for a total of 156.5 hours a week.

The denial is overturned.

This is a patient with chronic medical problems including dementia, diabetes, cerebrovascular accident (CVA), and kidney disease.  The patient lives with their spouse in a 1 bedroom apartment with 2 flights of stairs to reach the entryway.  The insurer approved personal care services (PCS) 71.5 hours/week.  The request is for PCS 22 hours a day, 5 days a week, 23.5 hours a day, 1 day a week, and 23 hours a day, 1 day a week for a total of 156.5 hours a week.

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "severely impaired."  The patient is reportedly totally dependent for performing Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient is also reportedly totally dependent for bathing, personal hygiene, upper body dressing, locomotion and toilet use.  The patient is reportedly unable to ambulate and bedbound.  However, the patient reportedly crawls over the railed bed-rails and wanders around the home at night.  Maximal assistance is reportedly needed for lower body dressing and eating.  Extensive assistance is reportedly needed for bed mobility.  The patient's activities of daily living (ADL) status and overall self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  The patient is reportedly incontinent of bladder and occasionally incontinent of bowel.  

The letters from the patient's treating physician describing the patient's clinical condition and reported need for "12 hours of care per day and 12 hours of care per night, 7 days a week" was reviewed.  The physician does not provide associated treatment notes to support their assertion of the patient's functional incapacity.  However, documentation is included in the hospital discharge summary report.  The patient was admitted and treated for urosepsis and mental status changes.  The patient was admitted to the hospital for traumatic subdural hematoma, intra-parenchymal hemorrhage and hemorrhagic contusion and approximately 2 months later again for urosepsis.  

The patient's functional impairments are at a level of unpredictability as to require PCS 22 hours a day, 5 days a week, 23.5 hours a day, 1 day a week, and 23 hours a day, 1 day a week for a total of 156.5 hours a week.  The combination of the physician letters, UAS report and hospital records clearly demonstrate the patient's clinical condition, multiple impairments and functional incapacity.   The patient requires routine repositioning in bed at least every 2 hours.  Based on the clinical records, a live-in PCA is unlikely capable of consistently obtaining approximately 5 hours of uninterrupted sleep over the course of a 24 hour shift.  It is also agreed that attention to the patient's functional needs are more appropriately provided and maintained by increasing PCA services to 22 hours a day, 5 days a week, 23.5 hours a day, 1 day a week, and 23 hours a day, 1 day a week for a total of 156.5 hours a week.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care services (PCS) 22 hours a day, 5 days a week, 23.5 hours a day, 1 day a week, and 23 hours a day, 1 day a week for a total of 156.5 hours a week is substantiated.