Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, essential hypertension, gastroesophageal reflux disease, hyperlipidemia, hypothyroidism.

Treatment personal care services (PCS), level 2 of 6 hours per day, 7 days per week for a total of 42 hours per week.

The insurer denied coverage for personal care services, level 2 of 6 hours per day, 7 days per week for a total of 42 hours per week.

The denial is overturned.

The patient is a male with a past medical history of coronary heart disease, essential hypertension, gastroesophageal reflux disease, hyperlipidemia, hypothyroidism, osteoarthritis, insomnia, dizziness and gait abnormality. The patient was receiving personal care services (PCS) level 2, 5 hours per day, 7 days per week, total of 35 hours per week. The patient requested increase of PCS to 6 hours per day, 7 days per week, total 42 hours per week, which was denied. 

The combined effects of osteoarthritis, neuropathy, peripheral artery disease (PAD), dizziness, fatigue produce greater physical impairment than each of these conditions alone. When these conditions co-exist treatment can be challenging. In older people, the risks of polypharmacy, medication side effects, and surgery often limit treatment options, and/or may create new problems.  Physical therapy is an option for non-pharmacologic pain management for some types of pain. The patient's treatment has included medication, surgical procedures, physical therapy, adaptive equipment/assistive devices. He may have periods of symptom relief; but it appears his overall functional ability and activity tolerance has declined. He is asking for more home care assistance, indicating he is feeling the increasing burden of performing daily activities. The functional report in the Uniform Assessment System (UAS) indicates the patient needs more assistance with several Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) compared to prior UAS, which is consistent with the chronic and progressive nature of several of the patient's medical conditions. 

Regarding the patient's mobility, the patient has difficulty standing up from a sitting position (which applies to transfers from chair, bed, toilet). For ambulation, he has slow, unsteady gait, which is due to combined effects of osteoarthritis (possibly affecting lumbar spine and lower extremity joints); gait problems associated with peripheral neuropathy, foot drop, claudication; dizziness, impaired balance. There were two falls identified in the available records. 

Transfers and walking occur at various unscheduled times of the day; and so, the patient needs a caregiver present throughout the day when needed for these activities. Assistance and supervision/cues for safety with ADLs is an important aspect of care provided by personal care aides. Caregiver assistance with mobility can help decrease the occurrence of falls.

The information provided for review indicates the patient needs assistance for most IADLs and ADLs throughout the day. Therefore, it is medically necessary and, in the patient's, best interest to have a caregiver present for a more extended period of the day to provide assistance with ADLs and IADLs during the hours the patient is most active. More PCS hours would accommodate the patient's need for assistance with mobility which occurs at various and unscheduled times during day inside his home and if he chooses to go outside. 

For older people, the effort of performing ADLs and household tasks with chronic symptoms such as pain and fatigue is stressful. Providing the patient with physical assistance can help to ensure effective and safe performance of ADLs and IADLs, and help relieve some of the physical burden the patient experiences with routine daily activities.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Services, Level 2 of 6 hours per day, 7 days per week for a total of 42 hours per week is reversed. Medical Necessity is substantiated.