Diagnosis: Hypertension, multiple sclerosis, and osteoporosis
Treatment: Personal care service 12 hours a day, 7 days per week, for a total of 84 hours per week
The insurer denied coverage for personal care service 12 hours a day, 7 days per week, for a total of 84 hours per week.
The denial is overturned.

This patient is an adult female with chronic medical problems including hypertension, multiple sclerosis, and osteoporosis. She lives alone in a 1-bedroom apartment. The insurer approved personal care services (PCS) 9 hours/day, 7 days/weeks totaling 63 hours/week and she is requesting an increase to 12 hours/day, 7 days/weeks totaling 84 hours/week.

According to the recent Uniform Assessment System (UAS) report, the patient is described as "alert and oriented X 3, self-directing." Her cognitive skills are "independent." The patient requires maximal assistance for bathing, lower body dressing, and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. Extensive assistance is needed for personal hygiene, upper body dressing, and bed mobility. She is "non-ambulatory due to paraplegia."

Her significant functional impairments support the medical necessity of increasing PCS. From a physical medicine and rehabilitation perspective, the requested PCS 12 hours a day, 7 days per week, for a total of 84 hours per week is medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for personal care service 12 hours a day, 7 days per week, for a total of 84 hours per week is overturned. Medical Necessity is substantiated.