Diagnosis: PMH (past medical history) of HTN (hypertension), HL (hyperlipidemia), CAD (coronary artery disease), DM (diabetes mellitus), arthritis and recurrent falls
Treatment: Personal Care Services (PCS) 9 hours a day, 7 days a week, for a total of 63 hours per week
The insurer denied the Personal Care Services (PCS) 9 hours a day, 7 days a week, for a total of 63 hours per week
The denial is overturned

The patient is a female. She has PMH (past medical history) of HTN (hypertension), HL (hyperlipidemia), CAD (coronary artery disease), DM (diabetes mellitus), arthritis and recurrent falls. She reportedly has weakness, immobility and dementia. She has progressive functional decline. She has dysphagia and is at risk of aspiration and needs close supervision. She is also incontinent of bladder most of the time. The patient lives alone.

Under review is the request for Personal Care Services (PCS) 9 hours a day, 7 days a week, for a total of 63 hours per week.

Yes, the personal care services 63 hours/week are medically necessary.
The patient has multiple co-morbidities. She has recently experienced significant functional decline. The patient continues to deteriorate. The patient has worsening knee pain due to arthritis and has difficulty ambulating. The patient cannot use a walker due to left arm fracture and chronic bilateral shoulder pain. The patient has worsening progressive dementia.

The patient has swallowing difficulty and is at risk of aspiration. She needs constant supervision while eating. She is at risk of aspiration and acute respiratory failure without supervision. She needs help with preparing meals, laundry, shopping, dressing, bathing, toileting and all her ADLs (activities of daily living). The health plan's approved regimen of personal care service 49 hours/week is not adequate to meet this patient's needs.

Therefore, given the above, the requested personal care services 63 hours/week are medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has limited mobility with significant functional decline. The patient needs more hours.