Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease 
Treatment: Personal care services at 35 hours per week 

The insurer is denied coverage for personal care services at 35 hours per week. The denial is overturned. 

This is a female patient with extensive pulmonary disease and needs substantial assistance with daily activities. The patient had been receiving 35 hours of personal care services (PCS) per week. Following an assessment, the insurer determined that the patient needs only 16 hours per week to meet her daily personal care needs. The patient appealed the decision, which was denied. She is requesting an external appeal for approval to continue PCS 35 hours per week. 

The patient's physician (pulmonologist) submitted letters in support of the patient's appeal describing the patient's respiratory condition. It was noted the patient has COPD, asthma (noted as severe) and obstructive sleep apnea. She needs bronchodilator therapy (inhalation) every 4 to 6 hours. She becomes severely short of breath with minimal exertion and is easily fatigued. She has difficulty with her daily activities and needs assistance. The UAS medication list includes multiple bronchodilators (inhalation and oral); corticosteroids (inhalation and oral). The physician also noted the patient has had multiple hospitalizations. 

The patient needs extensive assistance with walking and toileting; therefore, she needs
assistance throughout the day, as these activities are not limited to 2 or 3 hours per day. She needs maximal assistance with meal preparation. Even if meals are pre-prepared for later in the day, it is likely some preparation and clean-up before and after each meal is needed. Considering the patient's difficulty with mobility, it is unrealistic to consider that she can effectively and safely manage all daily activities if she has assistance only 2-3 hours per day; and some of the aide's tasks are outside the home (e.g. shopping), and so the aide is not available to assist with ADLs when she is outside of the home. 

It is apparent that the patient needs substantial assistance with daily activities. Several of these activities occur throughout the day. The patient needs assistance with walking, toileting, and meals; activities which are not limited to 2-3 hours per day. The patient was receiving PCS 35 hours per week (5 hours per day). The question is not whether this is more than the patient needs; but is it enough. Due to the patient's symptoms from chronic pulmonary disease (dyspnea, poor endurance, fatigue, decreased exercise tolerance), exacerbated by pain and decreased mobility from arthritis, it is medically necessary for the patient to have caregiver assistance with most IADLs and ADLs as needed throughout the day. There are no informal caregivers identified; therefore, personal care services are indicated to provide the necessary assistance with IADLs and ADLs. The maximum number of hours recommended from this review is limited by the hours requested, i.e. 35 hours per week. 

Personal care services 35 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the continuation of personal care services at 35 hours per week is overturned. The medical necessity is substantiated.