Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension, diabetes, COPD (Chronic obstructive pulmonary disease) and osteoarthritis; status post bilateral hip and left knee replacements

Treatment: increase in Personal Care Services, 12 hours a day, 4 days a week for a total of 48 hours

The insurer denied coverage for increase in Personal Care Services, 12 hours a day, 4 days a week for a total of 48 hours

The denial is upheld

 
This is an elderly male with chronic medical conditions including hypertension, diabetes, COPD and osteoarthritis; status post bilateral hip and left knee replacements.  He lives alone in a 1-bedroom apartment and uses portable oxygen.  The patient's daughter is involved and directs his care.  The patient requested an increase in Personal Care Services (PCS) from 8 hours/day, 4 days/week to 12 hours/day, 4 days/week, denied by the insurer and leading to an external review.  

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive status is described as minimally impaired.  He is able to activate his Personal Emergency Response System (PERS) in case of an emergency.  The patient reportedly requires maximal assistance to total dependence for performing Instrumental Activities of Daily Living (IADL) tasks including shopping, ordinary housework and meal preparation.   He reportedly requires maximal assistance for bathing, lower body dressing and toilet use.  Extensive assistance is reported needed for personal hygiene, upper body dressing, eating, bed mobility, locomotion, toilet transfer and ambulation.   He reports being frequently incontinent of bladder and continent of bowel.  His Activities of Daily Living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.   There have been no reported falls over the prior 90 days.  

The patient's medical condition, physical limitations and functional ability are not at the level or unpredictable as to require the requested increase PCS 12 hours/day, 4 days/week for a total of 48 hours/week.  The letter from the patient's treating nurse practitioner (NP) was reviewed.  The NP describes the patient's underlying medical conditions, associated impairments and reported needed time for care/services.  There are no associated treatment notes to support her claim of the patient's reported functional incapacity.   Please note that aides cannot manage behaviors and/or medical conditions.  This is outside of their scope of practice.  This physician would agree the patient may benefit from additional supervision and monitoring; particularly for companion care and safety; given his potential falls risk.  However, safety monitoring under PCS does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by approved PCS from 8 hours/day, 4 days/week, informal care from family and Personal Emergency Response System (PERS).  

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 increase in Personal Care Services, 12 hours a day, 4 days a week for a total of 48 hours is not substantiated.