Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, Asthma, Osteoporosis

Treatment: Personal Care Services, 8 hours a day, 7 days a week

The insurer denied coverage for Personal Care Services, 8 hours a day, 7 days a week

The denial is upheld 

This is a patient with chronic medical problems including hypertension, asthma and osteoarthritis.  The patient lives with their spouse in a private residence.  The insurer approved personal care services (PCS) services 37 hours/week and the request is for 56 hours/week, leading to an external review.  

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as modified independent.  The patient reportedly requires maximal assistance for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for bathing and lower body dressing.  Extensive assistance is reportedly needed for upper body dressing and toilet use.  Limited assistance is reportedly needed for personal hygiene, bed mobility, locomotion, toilet transfer and ambulation (uses a walker).  The patient is independent with eating.  The patient reports being frequently incontinent of bladder and continent of bowel.  There has been one reported fall over the prior 30 days.  

The patient was seen by their provider for complaints of neck, back and shoulder pain.  Strength was generally normal, and gait was described as antalgic.  The provider recommended physical therapy and Tylenol.   The patient was also seen for "cardiology follow-up."  The patient complained of palpitations without chest pain, shortness of breath or leg swelling.  The patient was described as fully alert and oriented.  The cardiologist noted the patient "uses walker" for ambulation.  The patient was seen by the physician assistant (PA) for right knee pain.   The PA indicated the right knee was stable.  Strength (5/5) and range of motion  (0-120 degrees) were normal.  The PA concluded the patient was "doing well."  Physical therapy was again recommended.  

The patient's medical condition and physical limitations are not at a level or unpredictable as to require PCS services 56 hours/week.  This physician would agree, the patient may benefit from additional monitoring for safety; particularly due to their reported limited mobility and falls risk.  However, PCS service hours are approved primarily to provide hands-on assistance for completion of IADL/Activities of Daily Living (ADL) tasks when no else is available to provide assistance; not primarily for safety monitoring.  Based on the records reviewed, the patient's health and safety while in the home are appropriately provided and maintained by the approved PCS 37 hours/week.

The healthcare plan acted, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).   

From a physical medicine and rehabilitation perspective, PCS 8 hours per day, 7 days per week  is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Services, 8 hours a day, 7 days a week is not substantiated.