Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dementia, CAD, HTN,
vestibular dysfunction, lumbago, peripheral
neuropathy, anxiety, depression and insomnia
Treatment: Increase Personal Care Services from 56 Hours per Week to 24 Hours Per Day (Live-In)
The insurer denied the Increase Personal Care Services from 56 Hours per Week to 24 Hours Per Day (Live-In)
The denial is overturned.

The patient is a female. Her conditions include Parkinson's disease, dementia, CAD (coronary artery disease), HTN (hypertension), vestibular dysfunction, lumbago, peripheral neuropathy, anxiety, depression and insomnia. Her pain and joint stiffness limit her ability to perform ADLs/IADLs (activities of daily living/instrumental activities of daily living). She lives alone. This is an appeal for denial of increase in PCS (personal care services) from 8 to 24 hours per day, live-in. The patient has been approved for a total of 56 hours per week.

The patient was discharged from Rehab to home. She had been admitted to an acute inpatient level of care with GI (gastrointestinal) bleeding. UAS (Uniform Assessment System) evaluation performed shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting; limited assistance with bed mobility; and independent with eating. She had a fall and was found to have a mild T12 (twelfth thoracic spine vertebra) compression fracture. The patient refuses to wear diapers. She is frequently incontinent of urine. This evaluation compared to the previous evaluation shows increased level of assistance needed for walking, locomotion, toileting, dressing, and bed mobility.

A letter from the patient's son states the patient's condition has deteriorate since her back injury and she has progressing dementia, resulting in her inability to care for herself without assistance. He notes that the patient is bedbound and requires assistance multiple times during day and night to the bathroom and other ADLs (activities of daily living).

An appeal letter from an advocacy group states that the patient needs frequent assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. It notes that the patient has unscheduled needs, including diaper change.

A letter from the patient's provider states an increase in PCS (personal care service) is medically necessary for safety and well-being. They note that the patient became bedbound as result of recent hospitalization, has worsening cognition and limitations with ambulation. This includes assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.

Yes, the Increase Personal Care Services from 56 Hours per Week to 24 Hours Per Day (Live-In) is medically necesary.

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 options.

The requested health service is medically necessary, because it is consistent with generally accepted national standard of medical practice.  Withholding the increase in requested hours of services is reasonably expected to affect the patient's health adversely.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding.  Personal care service is necessary when assistance cannot be met from use of from informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  The requested PCS (personal care service) at 24 hours per day, live-in,were denied.  She has been approved for 56 PCS (personal care service) hours per week.

This patient has multiple chronic conditions, including dementia and is status post thoracic compression fracture.  Per the provider and son, the patient is bedbound since thoracic fracture.  UAS (Uniform Assessment System) evaluation performed shows the patient requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living) except eating.  This evaluation shows a decline in the patient's functioning when compared to the UAS (Uniform Assessment System) evaluation performed previously. There has been a significant decline in the patient's functional status to where she now requires more assistance with walking, locomotion, toileting, dressing, and bed mobility.  She is incontinent of bladder and has demonstrated the need for extensive assistance with ambulation/transfers for toileting during day and night.  This patient has continuous needs that cannot be met with the approved PCS (personal care service) 56 hours per week.  The proposed increase in PCS (personal care service) to a 24 hours per day, live-in, is medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.