Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 

The insurer denied Personal Care Services, Level 2: 24 hours per day (live-in), 7 days per week. 

The denial is overturned. 

This patient is a female with a past medical history of dementia with severe cognitive impairment, congestive heart failure, nutritional marasmus, severe aortic stenosis with palliative treatment goals, chronic pain with difficulty walking and history of falls, urinary incontinence, history of frequent urinary tract infection, and extensive reliance on assistance for activities of daily living (ADL)s. 

The health plan states that the request was made due to the need for constant supervision. They state that being able to wander is an indication that the patient can stand and walk. 
An advocacy report was filed on behalf of the patient. This document contains information from the patient's recent admission to home hospice, an overnight log detailing the events requiring assistance that the patient needed for a three-night period and excerpts from office visit notes from recent follow-up visit after emergency department visit for urinary tract infection and office visit with neurology. The patient frequently requires use of the bathroom, and she needs assistance with ambulation, toilet transfer, and return. The patient intermittently experiences shortness of breath and needs to be reminded to use her oxygen as she cannot initiate that independently. She needs assistance with changing into appropriate clothing. The patient does usually have one extended period of sleep lasting four to five hours, usually starting around midnight. The results of the Uniform Assessment System (UAS) note significant deterioration from prior UAS. 

At issue is the medical necessity of Personal Care Services, Level 2: 24 hours per day (live-in), 7 days per week. 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of Personal Care Services, Level 2: 24 hours per day (live-in), 7 days per week is medically necessary for this patient. 
This patient demonstrated significant functional and cognitive decline on her UAS. She now requires extensive to maximum assistance with activities of daily living and instrumental activities of daily living. Overnight logs demonstrate this as well, noting frequent need for overnight assistance with toileting, transfers, incontinence care, and direction for medical needs like oxygen use. There is sufficient justification that the patient's need for 24-hour care extends simply beyond her need for safety and security as the health plan asserted. The available evidence clearly demonstrates that the patient has a need for environmental and nutritional support functions, as well as personal care service functions which occur around the clock. It is not appropriate to consider the task-based assessment to determine the number of hours per week that is appropriate for a patient who is in need of 24-hour services, given that these services are required on a more continuous basis and are unpredictable based on the physiologic needs of the patient. Furthermore, there is significant evidence that if the patient is left alone and denied these services, that she would undergo rapid deterioration of her health, with likely resulting poor outcome, including high likelihood for skin breakdown due to incontinence and/or recurrent urinary tract infection. 

Therefore, the requested health service/treatment of Personal Care Services, Level 2: 24 hours per day (live-in), 7 days per week is medically necessary.