Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied: Personal Care Services (PCS), 24 hours a day, live-in, 7 days a week. 
The denial is overturned in part. 

The patient is a female with a past medical history significant for shortness of breath, panic attacks, gait abnormality, sleep disorder, vertigo, neck pain, depression, anxiety, palpitations, constipation, lumbar radiculopathy, hypertension, diabetes mellitus, incontinence, foot pain, decreased hearing, hyperlipidemia, fatigue and frequent falls.
This review is for the medical necessity of personal care services 24 hours per day 7 days a week live-in. The patient is currently receiving 24 hours per week. Additional services were denied based on medical necessity.

The requested health service is not medically necessary for this patient, however an increase to 49 hours per week is necessary.
Recommend overturning the decision in part. Patient needs additional medical services due to declining health status. Recommend 7 hours a day 7 days a week for a total of 49 hours a week of services.
Services were denied by her plan stating you need help preparing her meals, housekeeping, shopping, laundry, bathing, dressing, toileting, walking and personal hygiene. You need limited help with eating and turning in bed. You have a walker and wheelchair to help you moving in your residence. The nursing facility reports that you can walk with supervision with your walker. It also said that she can turn herself in bed. Incontinent supplies are provided.
Patient is requesting additional services on appeal due to natural aging, chronic diseases and negative health changes. 
Statement from the patient's physician states that the patient needs an increase in services due to help with her activities of daily living (ADLs), transferring, bathing, food preparation and shopping. She needs constant help and supervision day and night.
Uniform Assessment Tool (UAS) was reviewed. Hours Evaluation for Paraprofessional Support (HELPS) tool recommended 47 hours a week as services over 7 days.
The patient is an elderly female with multiple medical problems and declining health. Recent hospitalization secondary to blood clot resulted in extensive skilled rehab confinement. Patient was previously receiving services a total of 24 hours a week of services. Due to the patient's declining health noted on her recent UAS and HELPS tools, additional services are required. These additional services are for recommended care, activities of daily living (ADLs) and Instrumental activities of daily living (IADLs).
When approving services, there must be demonstrated need for ADLs or IADLs above and beyond observation and preventing falls. Services for preventing falls and observation are typically included in the provided services allowed for under the evaluation. Specifically, the aide must be performing a service such as in ADL or IADL to be a covered service. Aide services for watching the patient in the middle of the night without actually performing a medically necessary ADL would be considered observation and typically not a service provided under the plan. The documentation provided did not note specific needs for 24 hours a day 7 days live-in services.