Appeal type: Medical necessity
Decision: Overturned

Diagnosis: diabetes, osteoarthritis and anxiety disorder

Treatment: increase in personal care services to 24 hours per day, 7 days per week, mutually shared split shift

The insurer denied coverage for increase in personal care services to 24 hours per day, 7 days per week, mutually shared split shift

The denial is Modified
 

This is an elderly male with chronic medical problems including diabetes, osteoarthritis and anxiety disorder.  He and his wife receive mutually shared personal care services (PCS).   He is currently residing in an adult care facility and plans to return home.  The insurer approved PCS 8 hours/day, 7 days/week for a total of 56 hours/week.  The request is for PCS; 12 hours per day - 7 days per week; 12 hours per day - 7 days/week - for a total of 168 hours/week (mutually shared split shift); denied by the insurer and leading to an external review. 

The Uniform Assessment System (UAS) report was reviewed.  The assessment was performed via video teleconference.   The patient's cognition was described as "minimally impaired."  He is able to independently activate his Personal Emergency Response System  (PERS).  The patient reportedly requires maximal assistance to total dependence for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing, dressing, locomotion, toilet transfer/use and ambulation.  Limited assistance is reportedly needed for personal hygiene and bed mobility.  He is independent with eating.  The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel.   

The patient's ability to perform activities of daily living and self-sufficiency have reportedly declined  and deteriorated, respectively, over the prior 90 days.  There has been 1 reported fall over the prior 30 days.  The patient's cognitive and functional ability have also declined when compared to the prior UAS report.  

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested PCS; 12 hours per day - 7 days per week; 12 hours per day - 7 days/week - for a total of 168 hours/week (mutually shared split shift).  This physician would agree the patient may benefit from additional monitoring for safety; particularly due to his reported progressive cognitive decline, weakness and falls risk.  However, safety monitoring under PCS does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   This physician would also agree the patient's functional ability has declined and remains substantial.  Based on the submitted clinical records, the patient's health and safety are more appropriately provided and maintained at home by increasing PCS to 12 hours/day, 7 days/week; for a total of 84 mutually shared hours/week.  The patient may also have the option of restructuring and flexibly using the 84 PCS mutually shared hours weekly (perhaps 2 shifts) to better maintain and meet his functional needs.  

Based on the above, the insurer's denial must be modified. 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 an increase in personal care services to 24 hours per day, 7 days per week, mutually shared split shift services is not substantiated. 

However, increasing PCS; 12 hours per day - 7 days per week; for a total of 84 (mutually shared) hours/week is medically necessary.