Appeal type: Medical necessity
Decision: Overturned

Diagnosis: bipolar disorder, schizophrenia, chronic obstructive pulmonary disease (COPD), heart failure, morbid obesity, opioid dependence, hyperlipidemia, and stroke

Treatment: Personal care services (PCS), level 2, 8 hours per day, 7 days per week, for a total of 56 hours per week

The insurer denied coverage for PCS, level 2, 8 hours per day, 7 days per week, for a total of 56 hours per week

The denial is overturned

This female has extensive medical history associated with significant functional impairment for daily activities. She lives alone and receives PCS to assist with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The Uniform Assessment System (UAS) report indicates patient's family are informal helpers, but it is unclear how much assistance they provide and how often. The patient was receiving PCS 28 hours per week. The patient requested increase of services to 56 hours per week, which was denied. Appeal was requested, which upheld denial of PCS 56 hours per week, but the insurer increased PCS to 33 hours per week (5 hours per day, 5 days per week, 4 hours per day, 2 days per week). External appeal was requested. 

The most recent UAS provided for review was reviewed. The functional status report for IADLs indicated patient is totally dependent for ordinary housework, stairs, transportation; she needs maximal assistance for meal preparation, shopping; extensive assistance for managing finances and medications; limited assistance for phone use. For ADLs, she needs maximal assistance for bathing, dressing lower body, walking, locomotion, transfer toilet; extensive assistance for personal hygiene, dressing upper body, toilet use, bed mobility; limited assistance for eating.

Comparison of the 2 most recent UAS's identifies decline in function for several ADLs. 

Considering the patient's functional limitations, including limited use of her right upper extremity (noted as dominant side), it is unrealistic to expect the patient to provide adequate self-care for toileting and incontinence. Remaining in soiled diapers for extended periods of time is a source of discomfort for the patient and increases risk of incontinence associated skin damage (e.g., dermatitis, fungal infection). 

Toileting and incontinence occur at various unscheduled times throughout the day and so current PCS hours are insufficient to provide adequate care with toileting and incontinence. 

Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs must be considered in the determination of the patient's personal care service hours, which includes all IADLs, routine morning and evening ADLs (bathing, dressing, personal hygiene) and unscheduled recurring activities including toileting/incontinence care, mobility, meals.

Based on the information provided for review, it is apparent that the patient has substantial functional impairment for all daily activities. It is medically necessary, and in the patient's best interest to have caregiver assistance for a longer period of time each day to help the patient with daily activities during daytime hours when she is most active and needs the most frequent help. 

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 personal care services (PCS), level 2, 8 hours per day, 7 days per week, for a total of 56 hours per week is overturned. Medical Necessity is substantiated.