Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, hypertension, cognitive impairment, and osteoarthritis
Treatment: Personal Care services 12 hours per day, 7 days per week: total of 84 hours
The insurer denied coverage for Personal Care services 12 hours per day, 7 days per week: total of 84 hours
The denial is overturned

This elderly patient has extensive medical history associated with functional impairment and needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The records indicate he lives alone. He has a community caregiver with a power of attorney who provides some informal help; but the patient primarily depends on personal care services (PCS) for assistance with daily activities. In recent, the patient has had four hospital admissions, the most recent included two admissions approximately one month ago. When the patient was home in the past few months, he was receiving personal care services (PCS) 44 hours per week. The patient (via designee) requested an increase of PCS to 84 hours per week, which was denied.

The UAS (uniform assessment system) provided for review was completed several months ago (noted as first assessment; the patient was in a SNF (skilled nursing facility) for rehab at that time; not the same as the current SNF admission). The functional status report for IADLs indicated the patient was totally dependent for meal preparation, ordinary housework, managing finances, and shopping; he needed maximal assistance for transportation, managing medications, phone use, and stairs. For ADLs, the patient needed extensive assistance for bathing, personal hygiene, dressing upper and lower body, walking, locomotion, transferring to the toilet, toilet use; limited assistance for bed mobility; and setup help for eating.

The records included a case intake (appears to be from the insurer). The patient's caregiver reported the patient does not understand the use of the personal emergency response system (PERS) as an emergency call system. He uses it for non-emergencies (when he has a bowel movement). The caregiver reported in the SNF care plan meeting that the patient's cognition has been declining over the past year; he can no longer use a phone; and his safety awareness has diminished.

The UAS reported the patient has weakness of the lower extremities which limits walking and transfers. The UAS noted the patient has difficulty moving to a standing position, and recent PT (physical therapy) notes reported moderate assistance is needed for sit to stand transfers. The UAS also reported hand weakness and tremors which limits ability to perform manual tasks, such as toileting, dressing, personal hygiene, bathing, eating.

Considering the patient's medical history and functional status as reported in the available records, it is medically necessary for the patient to have assistance for all ADLs/IADLs when needed throughout the day. This includes household tasks, meal preparation/service (all meals), medication, bathing, personal hygiene, dressing, assist/encourage eating; plus, activities that occur at unscheduled and/or recurring times of the day and night, such as toileting/incontinence care; empty urinary drainage bag; transfers; walking; repositioning in bed. The patient needs assistance for proper and safe completion of all ADLs and IADLs in order to help prevent medical complications, such as malnutrition, weight loss, dehydration, hypoglycemia, skin damage, UTI (urinary tract infections), falls and injury.  

Recommendation is given to approve Personal Care Services, 12 hours per day, 7 days per week for a total of 84 hours per week.

Based on the above, the insurer's denial must be overturned. 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 increase in Personal Care services 12 hours per day, 7 days per week; total of 84 hours is substantiated.