Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, chronic obstructive pulmonary disease, coronary heart disease, diabetes, dementia.
Treatment: Personal Care Services (PCS) 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week.
The insurer denied coverage for PCS 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week.
The denial is overturned.

The patient is diagnosed with Alzheimer's disease, chronic obstructive pulmonary disease, coronary heart disease, diabetes, dementia, stroke, hypertension, hemiplegia, hyperlipidemia, osteoarthritis, monitoring, and xerosis cutis, who was described as bedbound and recently hospitalized with fluid overload. The assessment conducted noted the patient was totally dependent for activities of daily living to include bathing, personal hygiene, dressing the upper and lower body, locomotion, transferring to the toilet, toileting in general, bed mobility, and required extensive assistance with eating.  The current plan approval indicated that the patient was receiving PCS 24 hours a day, 7 days/week (live-in) for a total of 91 hours/week. She received a denial for coverage of personal care services (PCS) 24 hours/day, 7 days/week (split shift) for a total of 168 hours/week. The indication was that time had already been allotted to assist the patient with all daily tasks, and her needs could be met with live-in services. It was noted that the patient received hospice services but was unable to care for herself. She needed to be repositioned every 2 hours to prevent bedsores and required an increase in home care hours to meet her needs.  

With the patient's additional cognitive disabilities due to dementia and Alzheimer's disease, she is not fully aware of the dangers she is putting herself and throughout the night by changing her sleeping position. It was therefore necessary that the patient remain in her Fowlers position, which would require being lifted several times during the night and alternating the position of pillows to prevent pressure wounds from developing given that she is only able to lie in one position. The daughter stated that while the patient has a live-in aide, the aide does not tend to her throughout the evenings, as they are only getting paid for a certain amount of hours. The daughter also noted that with the patient on diuretics to help manage chronic congestive heart failure, she saturates her adult diapers, requiring changing throughout the evening. This also helps to prevent skin breakdown and ulcerations. The daughter stated that the intention for the increase in hours was to help her mother about the remainder of her days in the comfort of her home. The daughter is unable to assist in around-the-clock care due to her work responsibilities. This review pertains to the denial of coverage for personal care services (PCS) 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week. 

Current medical literature notes that personal care services allow individuals to remain in the comfort of their own home to receive treatment rather than living in a long-term care facility/nursing home. It was therefore determined that the request submitted for personal care services (PCS) 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week is medically necessary. The provided documentation confirmed that not all the patient's needs were being met with the current level of care. As such, the personal care services (PCS) 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week was medically necessary.

Based on the above, the insurer's denial must be reversed. 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 personal care services (PCS) 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week services is substantiated.