Diagnosis: HIV (human immunodeficiency virus), opioid dependence gait disorder, hepatitis C, polyneuropathy, and anxiety disorder
Treatment: Continued Long Term Custodial Care
The insurer denied the Continued Long Term Custodial Care
The denial is upheld.

The patient is an adult female with HIV (human immunodeficiency virus), opioid dependence gait disorder, hepatitis C, polyneuropathy, and anxiety disorder. The request is for continued Long Term Custodial Care Service. A Patient Review Instrument (PRI) notes that the patient requires intermittent supervision/minimal physical assistance with eating; wheels with no supervision or assistance; requires one person to assist with transfers but can participate; is continent of bowel and bladder and requires supervision for toileting. Physical therapy notes the need for minimal to contact guard assistance for toilet transfer. Notes indicate that she can propel 75 feet in her wheelchair. Documentation from psychiatry indicates "no profound depression" with insight and judgement at baseline. The patient was discharged to the community.

The health plan approved coverage of the request for Long Term Custodial Care for 5 weeks but denied coverage of continued Long Term Custodial Care onward, noting that the patient could perform many activities of daily living and direct their care. The denial notes that the patient will have personal care services and equipment to meet their needs in the community.

The denial was appealed, and the plan upheld the denial of the Long-Term Custodial Care onward, noting that the patient's needs could adequately be managed at a different level of care such as outpatient or home care program.

An appeal letter notes that the patient is wheelchair bound and has limited support in the community and requires extensive 24/7 assistance with activities of daily living. The letter notes that she is a fall risk and has a history of depression.

The Continued Long Term Custodial Care was not medically necessary.

The documentation does not reflect clinical findings that support the need for Long Term Custodial Care onward. While the appeal documentation argues that the patient requires 24/7 care, the documentation notes that the patient is able to accomplish many of her activities of daily living with minimal assistance, including toileting, eating and dressing. She is able to transfer with assistance. The psychiatry documentation does not reveal any severe behavioral concerns. Based on the documentation, the patient's needs could be met with personal care services, safety equipment, and physical therapy in the community setting. The medical literature does not suggest a significant difference in outcomes between long-term custodial care and community care with appropriate services (Denham 2018). Thus, Long Term Custodial Care after the initially approved 5 weeks was not medically necessary.