Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ischemic heart disease, hypertension, osteoarthritis, type II diabetes mellitus, chronic obstructive pulmonary disease, B12 deficiency, muscle weakness.
Treatment:  Increase of Personal Care Services, Level II, 24 hours per day, 7 days per week (live-in).

The insurer denied the Increase of Personal Care Services, Level II, 24 hours per day, 7 days per week (live-in).  The denial is upheld. 

This female has chronic conditions including ischemic heart disease, hypertension (HTN), osteoarthritis (OA), type II diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), B12 deficiency, muscle weakness, insomnia, anger, depression/anxiety, history of frequent falls, and hypercholesterolemia.  The provider notes the patient's physical and mental status has deteriorated over last six months, and she cannot be left along during night time, but provider does not provide medical conditions that require night time Personal Care Services (PCS).  The patient lives alone.  She has short-term memory impairment.  Her daughter assists with making complex decisions.  Assessment shows the patient has minimally impaired cognition and requires: max assistance with meal prep, shopping, transportation, bathing, lower body dressing, walking, locomotion, and toileting; total dependence with housework; extensive assistance with managing finances and medications, and upper body dressing; limited assistance with phone use, and personal hygiene; independent withering; and supervision with bed mobility.  The patient is requesting increase in personal care services from ten hours per day, seven days per week (70 hours) to live-in personal care services.

No, the proposed live-in Personal Care Services are not medically necessary.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding.  Personal care service is necessary when assistance cannot be met from use of from informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Level II personal care service is indicated for individuals who need assistance with housekeeping, cleaning, meal preparation, grocery shopping, and laundry as well as assistance with personal needs, including bathing, dressing, grooming, toileting, walking, feeding, assisting with administering medications, preparing meals with special diets, and routine skin care.  

This patient's assessment does not support the medical necessity for live-in Personal Care Services.  The patient is not bed bound and uses a walker for ambulation.  The assessment performed shows the patient's functioning has improved since prior assessment performed.  The patient requires max assistance with meal prep, bathing, personal hygiene, lower body dressing, toileting, and walking.  The patient does not have night time medical conditions/needs that support the medical necessity of live-in Personal Care Services (PCS).  The approved 70 hours per week is sufficient to provide assistance with activities of daily living (ADLs) and personal care for this patient's scenario.  Withholding the requested live-in services is not reasonably expected to affect the patient's health adversely.