Diagnosis: End stage renal disease; Blindness.
Treatment: Increase Consumer Direct Personal Care Assistance Services 24 Hours Per Day 7 Days Per Week, A Total of 168 Hours Per Week, Split Shift.

The insurer denied the Increase Consumer Direct Personal Care Assistance Services 24 Hours Per Day 7 Days Per Week, A Total of 168 Hours Per Week, Split Shift.
The denial is overturned.

The patient is a female with PMH (past medical history) of DM (diabetes mellitus), neuropathy, poor balance and gait. She reportedly is blind, has end stage renal disease and is on long term hemodialysis. She needs extended hours of services. The patient needs more help with ADLs (activities of daily living) and help at night time.

Yes, the Increase Consumer Direct Personal Care Assistance Services 24 Hours Per Day 7 Days Per Week, A Total of 168 Hours Per Week, Split Shift, is medically necessary.
The patient has end stage renal disease and is on dialysis. She is blind and needs extended aid and services at home. She is blind and cannot perform her ADLs (activities of daily living). The patient is a fall risk due to blindness. She will benefit from 24/7 home health care support. She needs help at night time with going to the restroom.

Patient currently receives a total of 84 hours per week. She will need 24 Hours Per Day 7 Days Per Week, A Total of 168 Hours Per Week.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient needs extended hours because of her blindness. She is on dialysis 3 times a week, and will need more help at night time.