Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiovascular disease including heart failure, atrial fibrillation, placement of internal cardiac defibrillator (ICD), venous insufficiency. 
Treatment: Increase in Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week. 
The insurer denied coverage for increase in Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week. 
The denial is overturned. 
 
The records indicate the patient has cardiovascular disease including heart failure, atrial fibrillation, placement of internal cardiac defibrillator (ICD), venous insufficiency. UAS medication list includes amiodarone, digoxin (unclear if she is taking both), Entresto, metoprolol, furosemide, Eliquis, ASA (acetylsalicylic acid). The physician reported the patient has dyspnea with exertion which limits her mobility. As per UAS (Uniform Assessment System), the patient has fatigue to the extent that she is unable to finish daily activities. PT (physical therapy) notes indicated the patient had poor endurance. The physician's letter included lower extremity edema (this may be due to heart failure and/or venous insufficiency). As heart failure progresses, functional ability for activities of daily living decreases. It is likely that heart failure is a significant contributing factor to the patient's functional decline. 

Based on the records provided for review, it is medically necessary, and in the patient's best interest, to have 24-hour continuous (split shift) services. The additional service hours are necessary for activities of daily living (ADL) care; not for stand-alone safety supervision. Information supporting the need for 24-hour continuous (split shift) services includes: The patient has frequent bladder incontinence and at least occasional bowel incontinence, which needs to be managed promptly by the aide. The patient needs assistance with bed mobility for pressure relief on a regular basis (patient has recent h/o pressure ulcer). If the patient is not repositioned and remains in a soiled diaper for an extended time, she is at high risk for complications, such as skin damage, and infection (e.g., urinary tract infection (UTI)). The patient's mobility is poor; she has history of falls. She is at a high risk for falls if she tries to get up from bed or chair unassisted; and so help needs to be available when the patient wants to move around her home (which has been reported to occur during the day, and at night). 

Based on information provided for review, the patient's ADL / instrumental activities of daily living (IADL) care needs include: housekeeping; meal preparation; medications, bathing, dressing, personal hygiene, eating, and unscheduled and/or recurring ADLs during the day and night (toileting/incontinence care, out-of-bed mobility, bed mobility, repositioning,). Considering the frequency and level of care the patient needs for ADLs and IADLs, it does not appear that a live-in aide can consistently have 8 hours of sleep per day, including 5 uninterrupted hours of sleep per day. At this time, based on the information provided for review, the patient's daily care needs can be best served with 24 hour continuous (split shift) services. 

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 an increase in Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week services is substantiated.