Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, hypothyroidism, hyperlipidemia, degenerative joint disease (DJD), chronic kidney disease (CKD), asthma, morbid obesity, heart failure, spinal stenosis, osteoarthritis, chronic respiratory failure, dementia, and blindness.

Treatment: Personal care worker (PCW) services 7 days per week, 24 hours per day live in, 91 hours per week

The insurer denied coverage for PCW services 7 days per week, 24 hours per day live in, 91 hours per week

The denial is overturned

 
This is an elderly morbidly obese patient with chronic medical problems including kidney disease, heart failure and osteoarthritis. She was recently admitted to a skilled nursing facility for subacute rehabilitation. The insurer approved PCW services 56 hours/week and the request is for 7 days per week, 24 hours per day live in, 91 hours per week, which is currently under review.

The Uniform Assessment System (UAS) report was completed several months ago. The patient's cognition is described as modified independent. She reportedly is totally dependent for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. Maximal assistance is required for bathing, personal hygiene, dressing, locomotion and toilet transfer/use. The patient is frequently incontinent of bowel and bladder. Extensive assistance is needed for bed mobility and eating. She is non-ambulatory and reported as bedbound. The UAS report is 3 months old and the patient's functional ability reportedly continues to decline.

The patient "is at high risk of recurrent pressure injury given her mobility, incontinence and inability to reposition without assistance." The treating physician also noted "the patient has suffered 3 hospital admissions for congestive heart failure, aspiration pneumonia and is now completely bedbound and incontinent of urine and stool. She is currently in a rehabilitation facility but the chances of recovery to a partially ambulatory state are nil."  

This physician would agrees with the insurer in the "Case Narrative Outline" regarding the recommendation for "a hospital bed with gel overlay. The gel overlay is a Group 1 Support Surface design with pressure-reducing property to reduce friction and shear of your skin, relieve pressure interface, maintain skin integrity as well as substitute repositioning needs in the bed to enhance your comfort while you are in bed." However, this recommended durable medical equipment (DME) (hospital bed with gel overlay) is no substitute for PCW services for repositioning the patient while in bed.  

The patient's condition, functional needs and bedbound mobility status are at a level and unpredictable as to require the requested PCW services 7 days per week, 24 hours per day (live-in) 91 hours per week.  The patient's health and safety are more appropriately provided and maintained by the requested PCW services 7 days per week, 24 hours per day (live-in) 91 hours per week.
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 personal care worker (PCW) services 7 days per week, 24 hours per day live in, 91 hours per week is substantiated.