Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Heart failure and myeloid leukemia

Treatment: PCS (personal care services) 12 hours a day, 7 days a week, for a total of 84 hours

The insurer denied coverage for PCS (personal care services) 12 hours a day, 7 days a week, for a total of 84 hours

The denial is modified
 

This is an elderly male with chronic medical conditions including heart failure and myeloid leukemia.  He lives with his son (who works full time) in a 1-story home.  The patient's personal care services (PCS) of 12 hours/day, 7 days/week for a total of 84 hours/week were reduced to 7 hours/day, 7 days/week for a total of 49 hours/week, leading to an external review.  

The Uniform Assessment System (UAS) report  was reviewed.  The patient's cognitive status is minimally impaired.  The patient is reportedly total dependent to maximal assistance 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, bed mobility, locomotion, toilet transfer and ambulation.  Limited assistance is reportedly needed for eating.  The patient uses a Foley catheter and is occasionally incontinent of bowel.  

The patient's activities of daily living (ADL) status and self-sufficiency have declined and deteriorated, respectively, 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 PCS 12 hours/day, 7 days/week for a total of 84 hours/week.  The letter from the patient's treating physician was reviewed.  He describes the patient's underlying medical conditions, associated impairments and reported necessary time for care/services.  There are no associated treatment notes that would further described the patient's clinical condition and reported functional incapacity.  This physician would agree the patient may actually require additional supervision and monitoring.  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.    

The patient's cognitive and functional ability has certainly declined when compared to the recent  UAS report done some  months ago, supporting an increase from the approved PCS 49 hours/week to 10 hours/day, 7 days/week for a total of 70 hours/week.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by increasing PCS to 70 hours/week, shared household responsibilities of the other adult living in the home, informal care from family and Personal Emergency Response System (PERS).  

Based on the above, the insurer's denial must be modified. 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 PCS 12 hours a day, 7 days a week, for a total of 84 hours services is not substantiated. However, PCS 10 hours per day, 7 days a week for a total of 70 hours per week is medically necessary.