Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, Depression

Treatment: Personal Care Services (PCS) 7 days per week, 12 hours per day (or 84 hours per week)

The insurer denied coverage for Personal Care Services (PCS) 7 days per week, 12 hours per day (or 84 hours per week).

The denial is upheld.

This is a patient with chronic medical problems including osteoarthritis, depression and hypercalcemia. The patient lives alone in a private residence. The insurer reduced the patient's personal care services (PCS) from 12 hours/day, 7 days/week to 8 hours/day, 7 days/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's ability to complete much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping ranges from limited to maximal assistance. The patient reportedly requires extensive assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Limited assistance is reportedly needed for personal hygiene, upper body dressing and bed mobility. Supervision is reportedly needed with eating. The patient is reportedly frequently incontinent of bladder and continent of bowel. The patient's activities of daily living (ADL) status and self-sufficiency have not changed and there have been no reported falls over the prior 90 days. The patient's cognitive status and functional ability are much the same when compared to the UAS report.

The letter from the patient's treating physician describing the patient's clinical condition and need for "assistance around the clock" was reviewed. The providers assertion regarding the patient's cognitive decline and "frequent falls" are not consistent with the UAS reports. The patient's provider does not provide any associated treatment notes to support her claim of the patient's reported functional incapacity. The patient's medical condition and physical limitations are not at a level or unpredictable as to require continuing PCS services 84 hours/week. The patient may benefit from additional monitoring for safety; particularly due to the patient's reported limited mobility and falls risk. However, PCS service hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no else is available to provide assistance; not primarily for safety monitoring (e.g., dementia). Based on the records reviewed, the patient's health and safety are appropriately provided and maintained with the approved PCS services 8 hours/day, 7 days/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). 

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 7 days per week, 12 hours per day (or 84 hours per week) is not substantiated.