Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, chronic kidney disease, anemia, colitis, constipation, functional diarrhea, osteoarthritis, blindness, chronic cough, gait instability and atrophy of right hand muscles. 
Treatment: Personal Care Services (PCS): 12 hours a day, 7 days a week, for a total of 84 hours. 

The insurer denied coverage for in Personal Care Services (PCS): 12 hours a day, 7 days a week, for a total of 84 hours. 

The denial is overturned. 
 
This is an elderly patient with a history of coronary artery disease, chronic kidney disease, anemia, colitis, constipation, functional diarrhea, osteoarthritis, blindness, chronic cough, gait instability and atrophy of right hand muscles. It is noted, the patient lives alone. Per the Visiting Doctor's follow up home visit note, the patient is relegated to the bed after the aide leaves due to blindness and severe gait instability. Assistance is needed with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient was approved for personal care services (PCS) nine (9) hours a day, seven (7) days a week. An increase to 12 hours per day is requested, which is under review. 

An increase in Personal Care Services (PCS): 12 hours a day, 7 days a week, for a total of 84 hours is considered medically necessary for this patient. 

The patient is totally dependent on her aide and is in bed when they are not around. The patient cannot do any of her activities of daily living (ADLs). As such, the request is appropriate. 

"This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems." (Hirdes, J. P. et al. 2022). 

Per Landers, S., et al., (2016), "Medicare skilled home health" care or "home health care" refers to services offered by Medicare-certified home health agencies under the Medicare home health benefit. By contrast, "home-based care" refers to a wide array of different types of care provided in the home by a wide range of parties. The continuum of different types of home-based care delivered in the home varies in terms of different dimensions, including acuity, type of care provided, and degree of physician involvement. Home-based care includes both formal and informal personal care services, Medicare skilled home health, physician house calls, and even "hospital-at-home" services." 

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 Services (PCS): 12 hours a day, 7 days a week, for a total of 84 hours is substantiated.