Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urine frequency, urgency, chronic kidney disease, dementia, and stroke
Treatment: Personal care services to 24 hours a day, 7 days a week (split-shift), for a total of 168 hours a week
The insurer denied coverage for personal care services to 24 hours a day, 7 days a week (split-shift), for a total of 168 hours a week
The denial is overturned

The patient has a history of urine frequency, urgency, chronic kidney disease, dementia, and a stroke which resulted in severe cognitive and functional deficits. She exhibits severe weakness along all cognitive domains. Her mobility is impaired. She requires assistance with ambulation, transfers, and toileting. 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 requested.

Fuchs, J., Gaertner, B., & Prutz, F. (2022), "Being able to perform activities of daily living is an important component of a person's ability to function. If these activities are impaired, support is needed. Using data from GEDA (geriatric emergency department accreditation) 2019/2020-EHIS (European Health Interview Survey), we present how many people aged 55 and older living in private households in Germany experience limitations in activities of daily living. Severe limitations in basic (fundamental) activities (e.g., food intake) are reported by 5.8% of women and 3.7% of men. The proportion increases with age as 13.4% of women and 9.0% of men aged 80 and older experience limitations. Severe limitations of instrumental activities of daily living (e.g., grocery shopping) are rather rare in participants less than 80 years of age. But at age 80 and older the proportion rises to 35.9% of women and 21.0% of men. A total of 68.1% of afflicted women and 57.5% of men receive help and support related to limitations of basic activities. Women are also more likely to report a lack of support (48.8% vs. 43.2%). The situation is slightly better with regard to instrumental activities... ADL (activities of daily living) and IADL (independent activities of daily living) limitations are associated to female gender, older age, lower education level, poorer health status, disease-related limitations, and impaired vision, hearing, and mobility."

Edemekong, P. F., Bomgaars, D. L., Sukumaran, S., & Levy, S. B. (2022), "ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual's ADL is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization, and use of paid home care. The outcome of a treatment program can also be assessed by reviewing a patient's ADLs."

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

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 patient has severe cognitive impairment as well as severe weakness among all her cognitive domains and needs 24 hours assistance.

The insurer's denial of coverage for 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 overturned. Medical necessity is substantiated.