Appeal type: Medical necessity
Decision: Overturned

Diagnosis: coronary heart disease, depression, vitamin deficiency, difficulty walking, dizziness and giddiness, hypertension, gastroesophageal reflux disease, anxiety

Treatment: increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 7 days per week 24 hours per day, live-in, 91 hours per week

The insurer denied coverage for increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 7 days per week 24 hours per day, live-in, 91 hours per week

The denial is overturned
 

The patient is an elderly female who lives alone in a one bedroom apartment. She has diagnosis of anxiety, coronary heart disease, depression, vitamin deficiency, difficulty walking, dizziness and giddiness, hypertension, gastroesophageal reflux disease, history of falling, localized edema, lower back pain, hyperlipidemia, urinary incontinence, bilateral knee pain, osteoarthritis, shortness of breath, and tinnitus. Her medications include Alprazolam, Bupropion, Clonazepam, Diclofenac Gel, Escitalopram, Famotidine, Fluticasone, Hydrochlorothiazide, Ibuprofen, Meclizine, Rosuvastatin, Vitamin B2, Vitamin C, and Vitamin D3. 

The provider sent a letter. He notes that her condition has deteriorated over the past few months, and she requires more attention and personal care. She currently suffers from anxiety, chronic tinnitus, and dizziness. He notes she cannot function independently, move around herself to get to the restroom, she cannot transfer on and off the toilet, cannot dress herself. She suffers from frequent panic attacks which paralyzes her for hours at a time. She needs additional hours during the day and specifically is requesting overnight hours.

The patient's psychiatrist sent a letter of appeal. He noted that the patient's condition has deteriorated over the past few months. She suffers from major depressive disorder and tinnitus disease. She suffers from multiple panic attacks a day which has caused shortness of breath, weakness, and dizziness. She is unable to independently move around by herself to get to the restroom, she cannot transfer onto and off the toilet, she cannot prepare food for herself. Her needs are constant, unpredictable, and unscheduled. Continuous home care service is the most appropriate level of care. 

This patient lives alone in a one bedroom apartment. She is severely impaired cognitively with periods of confusion per the mini mental examination. There is no history of wandering. She had one fall within the 30 days prior to the assessment. She is incontinent for bladder and continent for bowel. She is totally dependent for housework. She requires maximal assistance with meal preparation, toileting, and dressing her lower body. She requires extensive assistance with ambulation, toilet transfers, dressing upper body, eating, bed mobility, and personal hygiene. The information regarding her status and marked deterioration by multiple providers is noted and is persuasive. 

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 an increase in Personal Care Worker (PCW) services from 7 days per week, 7 hours per day, 49 hours per week to 7 days per week 24 hours per day, live-in, 91 hours per week is substantiated.