Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis and cervical spine arthritis
 
Treatment:  Personal Care Services Level 2, 12 Hours/day 7 Days/week

The insurer denied the Personal Care Services Level 2, 12 Hours/day 7 Days/week.  The denial was reversed.
This is a male patient with a history of type II diabetes mellitus with diabetic polyneuropathy, hypertension, benign prostatic hyperplasia, hyperlipidemia, osteoarthritis and cervical spine arthritis.  He underwent a right knee replacement leaving him wheelchair bound due to post-operative complications.  It was reported that the patient's right leg remains extended at all times while in the wheelchair.  He has the ability to wheel himself around, however he gets tired and fatigued.  He requires a one person assist for transfers, toileting, medication reminders, dinner, and assistance with bedtime.  Due to limited mobility of upper and lower extremities, he needs assistance to set up commode, help him transfer on/off commode to wheelchair, dressing and undressing, post elimination hygiene, sanitizing the commode.  It was reported that when the patient has attempted to make transfers on his own he has a history of falls. 
The patient has type 2 DM complicated by diabetic polyneuropathy (DPN).  The physician notes that patient has difficulty moving his fingers.  Exam was noted for significant ataxia and weakness of all limbs.  The UAS describes patient's difficulty propelling himself in wheelchair; numbness in hands, difficulty holding objects.  He has pain in both feet which is probably at least partly due to DPN (patient takes gabapentin).  The patient is mostly limited to locomotion by wheelchair due to complications from knee replacement and eventual removal of knee joint.  The patient is dependent on upper extremity function for his daily activities, including mobility around his apartment and all self-care tasks.  Most ADLs require some degree of manual strength and dexterity, which is impaired for this patient.  Many aspects of personal hygiene, bathing, dressing, toileting need motor and sensory function to perform tasks.  Weakness, numbness, pain in upper extremities can significantly limit ability for ADLs. 

The patient has osteoarthritis.  The patient experienced severe complications following right knee replacement.  Details are limited, but it appears the knee replacement was complicated by infection, several surgical procedures, and eventually had the knee prosthetic removed (and not replaced).  As a result, the patient is wheelchair dependent and needs to keep his right leg extended when in the wheelchair.  The UAS indicates pain in hips, shoulder and lower back, with pain fluctuating from mild (3/10) to severe (8/10).  Joint and back pain has significant adverse effect on the ability to perform daily activities.  The patient has lower extremity and back pain which creates an unstable situation when he tries to stand up and takes even the few steps needed to reach the toilet or bed (it is not clear how much weight-bearing he has on right leg).  The patient must rely on upper extremity strength and mobility for transfers, which appears to be diminished due to arthritis and DPN.  

Falls in elderly people have increased risk of serious injury (e.g. fractures, head trauma).  There is substantial morbidity and increased risk of death associated with falls.  Any serious injury could result in further functional decline.  Fall prevention is a priority for the patient's plan of care.  Providing assistance with ADLs during out of bed hours can help prevent adverse events.

The insurer did not act reasonably, with sound medical judgment, or in the patient's best interest.

The carrier's denial of coverage for 12 hours per day, 7 days per week for a total of 84 hours per week of Personal Care services, Level 2, is reversed.  The medical necessity is substantiated.