Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoarthritis, glaucoma and cerebral vascular accident (CVA)
Treatment: PCS (personal care services) 10 hours a day, 7 days a week, for a total of 70 hours a week
The insurer denied coverage for PCS 10 hours a day, 7 days a week, for a total of 70 hours a week.
The denial is modified.

This is a patient with chronic medical problems including osteoarthritis, glaucoma and cerebral vascular accident (CVA). She lives with her sibling in a 2-bedroom apartment on the 5th floor of an elevator accessible building. Under review is the medical necessity of personal care services (PCS) 10 hours a day, 7 days a week, for a total of 70 hours a week.

According to the Uniform Assessment System (UAS) report, the patient's cognition was described as "modified independent." She is alert and oriented (A+O) x 3, can activate the personal emergency response system (PERS) in an emergency and call 911. The patient requires maximal assistance for bathing. Extensive assistance is required for dressing, toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. The patient is independent with bed mobility and extensive assistance is needed for locomotion.

According to the telehealth visit note from nurse practitioner (NP), the patient is able to ambulate and has "VNS (visiting nurse service) home care to change LE (lower extremity) dressing." In an associated letter, NP indicated the patient's sister is the primary caregiver after PCS are completed for the day; however, she recently sustained a right humerus fracture which limits her ability to care for her sister. The patient's functional ability is much the same when compared to the UAS report. The combination of the patient's medical condition, functional impairments and limitations of informal caregiver assistance support the medical necessity for increasing the PCS to 8 hours/day, 7 days/week for a total of 56 hours/week; allowing the patient the ability to continue living safely and independent at home. The requested personal care services (PCS) 10 hours a day, 7 days a week, for a total of 70 hours a week is not medically necessary.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).

From a physical medicine and rehabilitation perspective, personal care services (PCS) 10 hours a day, 7 days a week, for a total of 70 hours a week, are not medically necessary. Increasing PCS to 8 hours/day, 7 days/week is medically necessary.

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 personal care services (PCS) 10 hours a day, 7 days a week, for a total of 70 hours a week services is not substantiated. The medical necessity for increasing the PCS to 8 hours/day, 7 days/week for a total of 56 hours/week is supported.