Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis.

Treatment: Personal care services of 24 hours a day, 7 days a week (split-shift).

The insurer denied coverage for Personal care services of 24 hours a day, 7 days a week (split-shift).

The denial is overturned.

According to the medical records, the patient is a female with difficulty walking and osteoporosis. The patient lives alone and her cognitive skills are moderately impaired; cues/supervision are required at all times. Maximal to total dependence/assistance is required for all instrumental activities of daily living (IADLs); supervision (bed mobility/eating), limited assistance (locomotion/walking), extensive assistance (toilet transfers/use, dressing) and maximal assistance (bathing) is required for activities of daily living (ADLs). Frequent bladder incontinence is noted. Personal care services of 24 hours a day, 7 days a week (split-shift) is requested.

"The results of GEDA (geriatric emergency department accreditation) 2019/2020-EHIS (European health interview survey) show in which areas of daily life older and very old people are impaired, give an impression of who is affected particularly strongly and indicate where support services are insufficient. As such, these results provide clues as to where support can be provided to enable older people to keep living in their own homes for a long time." (Fuchs, J. et al. 2022).

"Activities of daily living (ADLs) is an important measure of the quality of care provided in home healthcare (HHC), but few studies describe the ADLs of HHC patients. The objectives of this study were to (1) describe the types and levels of ADL dependency among patients receiving home care, (2) identify the risk factors for severe ADL dependency at admission, and (3) identify the predictors of ADL improvement during a HHC stay. This was a secondary data analysis of a 5% random sample of the national Outcome and Assessment Information Set (OASIS-C) for the year 2013. The dependent variables were severe ADL dependency level at admission and ADL improvement from admission to discharge. About two-thirds (65%) of the patients had severe ADL dependency (dependence in 7 or more ADLs) at admission. Older age, female gender, and impaired decision-making were associated with severe ADL dependency on admission. Of the 105,654 patients, 58.1% experienced ADL improvement. ADL improvement was associated with increasing home health care length of stay, being female, and prior inpatient stay. Clinicians, policy makers and agencies could focus on modifiable characteristics to achieve the goal of ADL improvement. (Osakwe, Z. T. et al. 2019).            
                                             
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  Per the review, patient needs maximal to total dependence/assistance is required for all instrumental activities of daily living (IADLs); supervision (bed mobility/eating), limited assistance (locomotion/walking), extensive assistance (toilet transfers/use, dressing) and maximal assistance (bathing) is required for activities of daily living (ADLs). This cannot be assured by 7 hours daily. Patient needs 24 hours assistance.      

Per the review, patient needs maximal to total dependence/assistance for all instrumental activities of daily living (IADLs); supervision (bed mobility/eating), limited assistance (locomotion/walking), extensive assistance (toilet transfers/use, dressing) and maximal assistance (bathing) is required for ADLs. This cannot be assured by 7 hours daily. Patient needs 24 hours assistance. Therefore, an increase in personal care services to 24 hours a day, 7 days a week (split-shift), for a total of 168 hours a week is considered medically necessary for this patient.

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person is overturned. Medical Necessity is substantiated.