Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic pain; decreased range of motion; dizziness; hearing and vision impairment; fatigue; poor endurance. 

Treatment: Personal Care Services (PCS), Level 2, 8 hours per day, 7 days per week, for a total of 56 hours per week. 

The insurer denied coverage for PCS, Level 2, 8 hours per day, 7 days per week, for a total of 56 hours per week

The denial is overturned. 

This is a female patient who has an extensive medical history and decline in functional ability for daily activities. She lives alone and has no informal caregivers to assist with instrumental activities of daily living (IADLs) or activities of daily living (ADLs). She receives Personal Care Services (PCS) 35 hours per week; 5 hours per day. She requested an increase of PCS to 56 hours per week, which was denied by the insurer. 

Uniform Assessment System (UAS) documentation was provided for review. For IADLs, the patient needs maximal assistance for all household related tasks and shopping; extensive assistance for stairs and transportation; limited assistance for finances and medications; setup help for phone use. For ADLs, the patient needs extensive assistance for bathing and lower body dressing; limited assistance for personal hygiene, upper body dressing and toilet use; all other ADLs are reported as setup help only. Compared to a prior UAS report, the current UAS report shows the patient needs more assistance with several ADLs including personal hygiene, upper and lower body dressing.

The patient has several medical conditions with associated symptoms that cause substantial limitation to daily function, including: chronic pain; decreased range of motion; dizziness; hearing and vision impairment; fatigue; poor endurance. As a result of these problems, the patient is at risk for adverse health and safety events if she does not have adequate assistance with daily activities that occur at various times of the day. Without adequate assistance, the patient is at risk for falls/injuries; increased frequency of incontinence; skin damage due to inadequate cleaning/hygiene following toileting and incontinence; impaired nutrition if patient misses meals. Therefore, it is medically necessary and in the patient's best interest to have caregiver present to address as many of these care needs as possible. 

The patient has medical conditions causing symptoms and functional impairment that limits her ability to safely and properly complete many daily activities, and place her at risk for various adverse health and safety events. The patient would benefit from additional PCS hours to meet more of her daily care needs. The concern is whether personal care services 56 hours per week is sufficient to meet the patient's daily care needs; as several of the daily activities that require assistance occur at various unscheduled times of the day; some ADLs are needed morning and evening, and the patient needs to have all her meals prepared and easy to access.  The number of PCS hours that can be approved from this review is limited by the hours requested; in this case 56 hours per week. The patient may wish to split her hours each day (if that is possible) to provide assistance at times of the day that cannot be covered with 8 consecutive hours. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Personal Care Services (PCS), Level 2, 8 hours per day, 7 days per week, for a total of 56 hours per week is overturned. Medical necessity is substantiated.