Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ulcer of heel.
Treatment: Long Term Custodial Care.
The insurer denied the Long Term Custodial Care. 
The denial is overturned.

The patient is a male with history of a fall. He sustained a left close ankle stress fracture. He developed edema, complex regional pain syndrome, and subsequent immobility.

The patient has a relevant past history of CVA (cerebrovascular accident) with right hemiparesis, uncontrolled Diabetes mellitus type 2 with neuropathy, peripheral artery disease status post right second toe amputation, hyperlipidemia, seizure disorder, diabetic foot ulcer, Morbid obesity, Hypertension, Atrial Fibrillation, major depressive disorder, Vitamin D deficiency, BPH (benign prostatic hyperplasia), etc.

The patient has a right plantar decubitus ulcer.

Prior to admission, the patient was independent and living in a shelter and receiving assistance from the church. He has no family support.

The patient was admitted to a Long-Term Custodial Care (LTCC) facility. While he has remained medically stable, independent with propelling manual wheelchair, requiring minimum assistance with most ADLs (activities of daily living), including transfer out of bed with little assistance into a manual wheelchair, transfer, he needs 24/7 care, which he will also require after discharge. He is also at risk of falls and seizures. He has no family around, and nowhere to be discharged to.

Yes, the Long Term Custodial Care is medically necessary.
The continued stay in Long Term Custodial Care (LTCC) is medically necessary. The patient was admitted to a Long-Term Acute Care (LTCC) facility. While he has remained medically stable, independent with propelling manual wheelchair, requiring minimum assistance with most ADLs (activities of daily living) including transfer out of bed with little assistance into a manual wheelchair, transfer, he needs 24/7 care, which he will also require after discharge. He is also at risk of falls and seizures. He has no family around and nowhere to be discharged to.

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, despite being able to perform some ADLs (activities of daily living) with minimal assistance, the patient is at risk of falls and seizures. He requires 24/7 care along with treatment of non-healing wound due to peripheral arterial disease as a complication of Diabetes mellitus.

Four more weeks from the date of this report is recommended for approval before the patient is re-evaluated, making it around four months. His multiple medical issues will make it difficult for him to be discharged.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The continued stay in a long-term custodial care is medically necessary, with clinical evidence, as stated above, of general debility and increased risks of fall and seizure and needing 24/7 care on discharge with no family support.