Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, pancreatic cancer
Treatment: Increase in Personal Care Services (PCS) from 42 hours/week to 24 hours/day (live-in)
The insurer denied the increase in PCS from 42 hours/week to 24 hours/day (live-in).
The denial is overturned.

This female patient has several chronic conditions, including dementia and pancreatic cancer receiving palliative care. She lives alone. She is appealing denial of an increase in personal care services (PCS) from 42 hours/week to 24 hours/day, live-in.  

Nursing assessments showed the patient needs maximum, extensive, or total assistance with bathing, personal hygiene, dressing lower body, toilet use, financial and medication management, meal preparation, and housework. Her functional status has declined. She has fallen multiple times. A statement states the patient requires 24-hour care due to her unscheduled needs. A letter from her daughter notes the patient's health has declined. She is bed bound and needs assistance day and night to be maneuvered in bed. She is unable to transfer, stand alone, or go to the bathroom. She has dementia and is disoriented most of the time. A letter from the provider notes the patient has been hospitalized. She is debilitated and requires 24/7 (24 hours/day, 7 days/week) nursing care. She requires help with transferring, bathing, dressing toileting, and feeding. A letter from another provider notes the patient has declined since hospitalization for pancreatic cancer. She has advanced osteoporosis with multiple fractures. She requires total assistance with daily activities. She requires an aide in every aspect of her life. She has no informal support.

Yes, the proposed treatment is medically necessary.

PCS are necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. 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. This patient has multiple chronic medical conditions and was recently diagnosed with pancreatic cancer. She is appealing denial of an increase in PCS from 42 hours/week to 24 hours/day, live-in. Nursing assessments showed the patient needs maximum, extensive, or total assistance with bathing, personal hygiene, dressing lower body, toilet use, financial and medication management, meal preparation, and housework. The appeal statements note there has been a decline in the patient's functional status since hospitalization. She is debilitated and requires 24/7 nursing care for assistance with all ADLs. She is unable to transfer, stand alone, go to the bathroom, or reposition in the bed without assistance. She is incontinent. This information provided supports the patient has needs that require 24-hour assistance. The proposed increase to 24 hours/day, live-in, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The proposed treatment is medically necessary.