Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 DM (diabetes mellitus), diabetic neuropathy, hepatitis, hypertension, hyperlipidemia, chronic kidney disease, bipolar disorder, GERD (gastroesophageal reflux disease), allergic rhinitis, TBI (traumatic brain injury)/seizure prophylaxis, polysubstance abuse, stroke, hypothyroidism, and peripheral arterial disease. 
Treatment: Long Term Custodial Care
The insurer denied the Long Term Custodial Care
The denial is overturned.

The patient is a male. His history includes Type 2 DM (diabetes mellitus), diabetic neuropathy, hepatitis, hypertension, hyperlipidemia, chronic kidney disease, bipolar disorder, GERD (gastroesophageal reflux disease), allergic rhinitis, TBI (traumatic brain injury)/seizure prophylaxis, polysubstance abuse, stroke, hypothyroidism, and peripheral arterial disease.  These conditions are managed with approximately 20 medications.  He is appealing denial of long term custodial care.  This service was denied because it was determined that needs could be met in a community setting.

The patient was transferred from a facility and admitted, after presenting with dyspnea and being diagnosed with pneumonia.  He was also found to have SVT (supraventricular tachycardia) and had beta blocker dosage increased.  Psychiatry consultation performed during admission notes the patient is stable because of being in a controlled supportive environment for the last two and a half years, where he receives medications supportive psychotherapy and help with basic needs.  He is not severely mentally or psychiatrically ill.  His diagnoses include mood disorder and personality disorder.  It is stated that the patient would not survive outside of this environment, and that the patient is not capable of monitoring his own medications.  He has no family support.  The patient's appeal statement notes that he is unable to care for himself and needs assistance.  He states he would like to return to his original facility.

Yes, the Long Term Custodial Care is medically necessary.
Medically necessary services are those which are:
-safe 
-effective
-generally accepted national standard of medical practice 
-not provided primarily for convenience of the patient or the practitioner 
-the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested long term custodial care is medically necessary, because it is in accordance with generally accepted national standard of medical practice.

Custodial care may be indicated for individuals that do not need skilled nursing care, but require assistance with ADLs (activities of daily living).  Determination of long term custodial care should be based on the complexity of care and medical supervision required.  This patient does not require skilled nursing care.  However, he has several chronic medical conditions and persistent mental illness that interferes with his ability to live in the community.  He requires daily supervision and assistance medication management that includes approximately 20 medications per day.  Psychiatric evaluation supports long term custodial care and states the patient is incapable of monitoring his own medications. There are no other reasonable support systems.  The requested long term custodial care is therefore medically necessary.