Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, seizures, paroxysmal atrial fibrillation, RA (rheumatoid arthritis)

Treatment: Personal Care Services (PCS), 9 hours a day, 5 days a week and 4 hours a day, 1 day a week for a total of 49 hours a week

The insurer denied coverage for Personal Care Services (PCS), 9 hours a day, 5 days a week and 4 hours a day, 1 day a week for a total of 49 hours a week

The denial is overturned

This case involves an adult with multiple diagnoses consisting of a history of stroke, seizures, paroxysmal atrial fibrillation, rheumatoid arthritis, hypertension, and osteoporosis who required total dependence on others for meal preparation, housework, walking, and locomotion.  According to the assessment the patient was residing in a skilled nursing/rehabilitation center.  She was found to be independent with decision-making and had intact memory. She had no hearing abnormalities and only minimal vision difficulties. The report confirmed that the patient required total dependence on others for meal preparation, maximal assistance for ordinary housework, extensive assistance with managing finances and medications, and was totally dependent for transportation. She required maximal assistance with bathing and extensive assistance with personal hygiene in general along with dressing. She was totally dependent for mobility and required maximal assistance with toileting transfers and use. She needed extensive assistance with bed mobility and limited assistance with eating. She used a wheelchair or scooter to get around and was noted to have infrequent incontinence for both bladder and bowel. She endorsed mild pain occurring intermittently controlled adequately by therapeutic measures. She had no history of recent falls, and no emergency room visits within the last 90 days of the assessment. She had strong social support and was found to have a body mass index of 29.8. At the time of the assessment, the patient was receiving daily wound care for pressure ulcers on her foot. She was recommended for Personal Care Services (PCS), 9 hours a day, 5 days a week and 4 hours a day, 1 day a week for a total of 49 hours a week.  

Current medical literature notes that personal care services allow patients with disabilities to remain in the comfort of their home environment while receiving the treatment/care that they need to maintain a good quality of life. The records provided for the review stated that the patient was previously approved for 38 hours of personal care services a week at 5 hours a day, 4 days a week and 6 hours a day, 3 days a week. Given that the patient and her spouse live alone, and with the spouse away for up to 10 hours a day for work-related obligations, it would be appropriate to increase the PCS hours to 9 hours a day to address the needs of the patient.  This will ensure that she receives the necessary care to keep her safe throughout the day while her spouse is away. Based upon the provided documentation, the increase in PCS hours is appropriate. As such, the request for Personal Care Services (PCS), 9 hours a day, 5 days a week and 4 hours a day, 1 day a week for a total of 49 hours a week is medically necessary.

Based on the above, the insurer's denial must be overturned. 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), 9 hours a day, 5 days a week and 4 hours a day, 1 day a week for a total of 49 hours a week services is substantiated.