Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis.
Treatment: Custodial care (long term care).

The insurer denied the Custodial care (long term care).  The denial is overturned.

The patient is a male with history of general debility and gait dysfunction secondary to right shoulder osteoarthritis after fracture with chronic dislocation, polysubstance abuse, drug intoxication, alcohol abuse, obstructive hydrocephalus and thrombocytopenia. The patient' s relevant medical history also include diabetes mellitus, altered mental status, mood disturbance, and insomnia. He requires support and assistance for all his activities of daily living (ADLs), and he is wheelchair bound; he is a high risk for falls and concomitant injury due to debility; his gait is dysfunctional, and he has impaired balance.

The patient is alert and oriented times three (AAOx3), able to participate in most activities, and physical therapy stated that the patient had reached practical functional goals and discharge, as he was able to ambulate 70 to 140 feet times three with rolling walker with one support also requiring support for bed mobility and other transfers as well as safety for ambulation with wheelchair behind him.

Yes, the proposed treatment is medically necessary.

The requested transfer to a long-term custodial care facility is medically necessary because the patient is a high-fall risk and requires support and assistance with most activities of daily living (ADLs), including ambulation, bed-mobility and transfers. This is unlikely to get better because of the patient's baseline medical conditions, including obstructive hydrocephalus, diabetes mellitus, chronic right shoulder dislocation with associated osteoarthritis, along with gait dysfunction and impaired balance.  The patient needs to be in long-term custodial care because he needs help with the above functionality, and as of the time of discharge from physical therapy, the patient required support and assistance with every activity of daily living (ADL).

Custodial care is needed when the patient requires:  1) Non-health-related services, such as help with daily living activities. Examples include eating, dressing, bathing, transferring and ambulating, or 2) Health-related services that can safely and effectively be performed by trained non-medical personnel and are provided for the primary purpose of meeting the personal needs of the patient or maintaining a level of function as opposed to improving that function to an extent that might allow for a more independent existence.

In this instance, the above do exist for this patient and are unlikely to improve, as stated earlier due to other comorbidities.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

The health plan has not acted reasonably in this instance, and its decision was without sound medical judgment, which was not in the best interest of the patient because, as stated above, the continued stay in a long-term custodial care is medically necessary with clinical evidence as stated above of general debility and decreased activities of daily living (ADLs) associated with increased high risk of falls.