Diagnosis: Chronic Obstructive Pulmonary Disease (COPD).
Treatment: Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week - Total of 168 Hours per Week (Split Shift).
The insurer denied Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week - Total of 168 Hours per Week (Split Shift).
The health plan's determination is overturned.

The patient is a female with past medical history of hypothyroidism, obstructive sleep apnea, coronary artery disease, congestive heart failure (CHF), hyperlipidemia, hearing loss, chronic obstructive pulmonary disease (COPD), oxygen dependence, bipolar, morbid obesity, urinary incontinence, bowel incontinence, diabetes mellitus type 2, gout, and history of breast cancer who had been assigned PCS (personal care services).

Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week - Total of 168 Hours per Week (Split Shift) are medically necessary for this patient.
There is documentation of worsening physical functioning following hospitalization and subsequent rehabilitation stay. The patient has a continuous positive airway pressure (CPAP) device for chronic respiratory failure and the patient is unable to apply, remove, or adjust this device. The patient's home does not accommodate for a space for a PCS to sleep. The patient requires maximum assistance with transfer toilet and toilet use, therefore the patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's medical provider also documented the patient's toileting care needs at least every 2-4 hours in the overnight hours which would not allow a PCS the required 5 hours of uninterrupted sleep in the overnight hours. The requested increase in PCS services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment or medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCS services 24 hours/day, 7 days/week, split-shift, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.