Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, arthritis and asthma
Treatment: 24 hours per day (split shift), 7 days per week, for a total of 168 hours per week of Personal Care Services Level 2
The insurer denied coverage for 24 hours per day (split shift), 7 days per week, for a total of 168 hours per week of Personal Care Services Level 2.
The denial is overturned.
 
This is an advanced elderly patient with multiple medical problems that include heart disease, arthritis and asthma.  She lives with her (physically impaired) daughter in a 2 bedroom apartment.  The insurer approved personal care services (PCS) 12 hours/day, 7 days/week and the request is for 24 hours/day (split shift) 7 days/week; which is currently under review.   

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired.  She is totally dependent for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She reportedly requires maximal assistance for bathing, lower body dressing and toilet use.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility, locomotion, toilet transfer and ambulation.  Eating reportedly requires limited assistance.  She is frequently incontinent of bowel and bladder.

During the UAS evaluation, the patient was found on the floor by the evaluating nurse.  "Daughter reported that she got up at 7am this morning and she found member on the floor, but she can't pick member up due to daughter had fracture on her left knee.  Nurse also unable to pick member up. Nurse waited for member's aide (to) come. Nurse and aide helped put member in wheelchair.  Not any bruise or other injury during nurse home visit.  Reinforced on fall precaution and home safely during nurse home visit."  It was also noted the patient has been hospitalized on several occasions over the past 2 years due to falling with resultant multiple fractures (ribs, thoracic spine and hips).

The patient's clinical condition and functional deficits are at a level and unpredictable as to require the requested PCS 7 days per week, 24 hours per day split shift.  Her functional status has significantly declined when compared to the  prior UAS report.  Of particular concern is her limited mobility, multiple fractures and extremely high risk for further injury.  She requires routine repositioning in bed at least every 2-3 hours, while not allowing additional falls.  Based on the clinical records, a live-in PCA is unlikely capable of obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift.  This physician would agree that attention to the patient's functional needs is more appropriately provided and maintained by the requested PCS 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.

Based on the above, the insurer's denial must be overturned. 

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

The medical necessity for 24 hours per day (split shift), 7 days per week, for a total of 168 hours per week of Personal Care Services Level 2 services is substantiated.