Appeal type: Medical necessity
Decision: Overturned

Diagnosis: L3 (third lumbar) vertebral fracture

Treatment: Personal Care Worker (PCW) services of 7 days per week, 24 hours per day

The insurer denied coverage for PCW services of 7 days per week, 24 hours per day

The denial is overturned

The patient is a female with a past medical history of hypertension, chronic obstructive pulmonary disease, umbilical hernia, liver cirrhosis, left knee replacement, Alzheimer's disease, a lumber L3 (third lumbar) compression fracture affecting her gait, and idiopathic Parkinson's disease that was hospitalized with diagnosis of L3 (third lumbar) vertebral fracture. The patient was transferred from the hospital to a nursing home (NH) for short term rehabilitation. She completed restorative rehab. The patient's functional status has declined since this acute event, and it was determined by her physicians that she needs 24 hour personal care services at home. The patient is currently still residing in the NH until a safe discharge plan can be confirmed. Prior to the hospitalization, the patient was living alone in her home (private house with upstairs bedroom and bath/shower); and was receiving PCW services 28 hours per week. 

The patient also has diagnoses of depression and anxiety which are often associated with dementia. Depression frequently occurs in people with dementia, and can result in further cognitive decline and functional impairment. For a person with dementia, changes in behavior may be a sign of depression (e.g. apathy, fatigue, loss of energy, changes in appetite, change in sleep pattern, increased agitation or irritability) Anxiety may also cause agitation and increased irritability.  

The patient has Parkinson's disease (PD) which affects motor function causing tremors, bradykinesia, rigidity, abnormal gait, postural instability, speech and swallowing problems. 

The patient needs assistance with all routine morning and evening activities of daily living (ADLs) (bathing, personal hygiene, dressing, toileting). Considering the patient's impaired mobility and cognitive impairment, with recent concern about decreased appetite, the patient needs a caregiver to prepare and serve all 3 meals each day. The nursing home orders include aspiration precautions (food is chopped). The patient may have some degree of dysphagia (possibly associated with Parkinson's disease). 

With the patient currently in a nursing home, it cannot be definitively determined what the patient's nighttime care needs will be at home. The nursing assistants (CNA) check all the NH residents through the night, and provide assistance when needed, including assistance to the bathroom, incontinence care, repositioning. However, some information from the available records may be useful to form an impression of the patient's care needs at night. 

There are 2 issues that must be confirmed prior to discharge. As per the daughter, the patient's home has two floors, with bedroom and shower upstairs. At the time of discharge from physical therapy, the patient had severe limitations with stairs and needed 2-person assist (for only 3 steps). The three physician letters of medical necessity have noted the patient will need a chair lift at home. The daughter acknowledges in her letter that a chair lift is necessary. Even with 24 hour live-in services, without the chair lift in place, and a plan for stair safety, discharge to her home would be unsafe. 

The other issue is assistance needed for toileting. The occupational therapy (OT) discharge note indicated that the patient can be toileted with min assist x 1; but at times needed 2-person assist. This must be clarified by staff before discharge. The patient lives alone; and there will not be a second person to assist the aide with toileting. The patient can return home only if all her daily care needs can safely (for patient and aide) be met with 1-person assistance.

With the understanding that the patient will be medically stable at the time of discharge, and the issues of stair safety, and 1 or 2-person ADL assistance (as noted above) are resolved in the discharge plan, then Personal Care Worker services 7 days per week, 24 hours per day, live-in, 91 hours per week is medically necessary. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the requested personal care worker (PCW) services of 7 days per week, 24 hours per day, live in is reversed. Medical necessity is substantiated.