top of page
< Back

202006-129188

2020

Centers Plan for Healthy Living

Managed Long Term Care

Vision

Home Health Care

Medical necessity

Overturned

Case Summary

Diagnosis: Vision-macular degeneration.
Treatment: Home health care.
The insurer denied Increase in Personal Care Aide services, for a Live-in Per Diem, for 24 hours per day.
The denial is overturned in whole

The patient with a past medical history of oxygen dependent chronic obstructive pulmonary disease (COPD), asthma, macular degeneration with severe visual impairment, severe right knee osteoarthritis, decubitus ulcer, hypothyroidism, occasional urinary incontinence, hypertension, and gastroesophageal reflux disease (GERD) .
Yes, the requested treatment for the t patient to receive 24 hours per day 7 days a week of full-time supervision from her Personal Care Aide services aid is medically necessary and appropriate.
With documentation provided by the patient's ophthalmologist, PCP and orthopedist, the patient would require more assistance with tasks of bed mobility, toilet use, transfer toilet, locomotion, walking, equipment management, bathing, personal hygiene and dressing lower body than assessed .
The patient has a new diagnosis of decubitus ulcer and per the PCP requires PCA service assistance overnight to prevent worsening bed sores as the patient is not able to change position in bed by herself. The PCP letter also noted the patient had become frailer requiring more help to accomplish ADL's.
Therefore, the personal care aide services are medically necessary for the live in per diem 24 hours per day 7 days per week.

bottom of page