Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, coronary artery disease
(CAD), peripheral vascular disease (PVD),
osteoporosis, polyneuropathy, and muscle
weakness
Treatment: Increase Personal Care Services to 24 Hours per Day (Split Shift) 7 Days per Week, a Total of 168 Hours per Week
The insurer denied the Increase Personal Care Services to 24 Hours per Day (Split Shift) 7 Days per Week, a Total of 168 Hours per Week.
The denial is overturned. 

This patient is a female with medical conditions including dementia, hypertension, coronary artery disease (CAD), peripheral vascular disease (PVD), osteoporosis, polyneuropathy, and muscle weakness.  The patient has a mutual case with her husband and together they received 12 hours per day personal care services (PCS).  The patient and her husband were admitted to a skilled nursing facility (SNF) after being admitted to the hospital for pneumonia due to coronavirus.  They were discharged.  The patient's granddaughter is requesting an increase in aide services as there was a decline in health following hospitalization.  

Assessment performed shows minimally impaired cognition and functional status:  maximal assistance with managing medications; extensive assistance with managing finances, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and limited assistance with phone use, and bed mobility.  

Assessment performed a month later shows changes include: total dependence with meal preparation, housework, and shopping; maximal assistance with stairs and shopping; and extensive assistance with phone use. 

Appeal notes that the patient has poor gait and unsteady balance.  She needs extensive one-person assistance with all activities of daily living (ADLs) and maximal to total assistance with all instrumental activities of daily living (IADLs).  Appeal letter from the provider states the patient has deteriorating cognitive and physical health.  It states the patient and her husband are completely depending on their home health aides for activities of daily lliving, they require assistance with movement and mobility, multiple day and. nighttime diaper changes, and bi-hourly turning and position during nighttime while in bed.   

The patient is appealing the denial for increase in personal care services from 84 hours per week to 24 hours per day, split shift, seven days per week.

Yes, the proposed treatment is medically necessary.

Medically necessary services are those which are:
safe 
effective
generally accepted national standard of medical practice 
not provided primarily for convenience of the patient or the practitioner 
the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient was recently hospitalized and in a skilled nursing facility (SNF) due to pneumonia.  She has several conditions, including dementia and poor gait and balance.  She is incontinent of bowel and bladder.  Assessments show this patient requires assistance with all activities of daily living and personal care needs.  Assessment performed compared to the previous assessment shows a decline in the patient's physical functioning.  It is noted after discharge from skilled nursing facility, the patient's cognitive and physical condition have deteriorated compared to prehospital status.  Appeal letters state that the patient needs extensive assistance with activities of daily living as well as diaper changes throughout the day and night and bed repositioning through the night.  

Based on the deterioration of this patient's condition and the assistance needed as noted above, the proposed increase in personal care services (PCS) to total 24 Hours per Day (split shift) seven days per week, total of 168 hours per week is medically necessary.