Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, glaucoma, osteoarthritis of knee, hypertension, and chronic right femoral neck fracture
Treatment: Increase in PCW (Personal Care Worker) services to 24 hours/day, split shift (Health plan approved increase to 24 hours/day, live-in)
The insurer denied the Increase in PCW (Personal Care Worker) services to 24 hours/day, split shift (Health plan approved increase to 24 hours/day, live-in).
The denial is overturned.

The patient is a female. Her medical conditions include dementia, glaucoma, osteoarthritis of knee, hypertension, and chronic right femoral neck fracture. Denial of increase in PCW (Personal Care Worker) services to 24 hours/day, split shift, is being appealed. The Health plan approved an increase to 24 hours/day, live-in.

UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with housework, and managing finances; maximal assistance with meal preparation, managing medications, shopping, bathing, lower body dressing, locomotion, and tolerating; extensive assistance with personal hygiene, and upper body dressing; and limited assistance with eating. She has bowel and bladder incontinence.

An appeal letter notes the patient's dementia has progressed and the patient has debility due to arthritis and hip fracture. It further notes the patient needs assistance both day and night with toileting/diaper change. It notes the patient requires personal assistance with ADLs (activities of daily living), both day and night.

An office visit notes the patient has poor mobility. She requires a semi electric hospital bed for elevation and transferring. She requires frequent body positioning. She is immobile and requires a patient lift for transfers from bed to wheelchair.

Yes, the Increase in PCW (Personal Care Worker) services to 24 hours/day, split shift, is medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase in PCW (Personal Care Worker) services to 24 hours/day, split shift, is being appealed. The health plan approved an increase to 24 hours/day, live-in.

This patient has multiple chronic conditions including dementia and mobility limitations. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living) and personal care needs. She has bowel and bladder incontinence. Due to immobility, she requires a patient lift for transfers to the wheelchair. Appeal statements note there has been a decline in the patient's cognitive and functional status. She has unscheduled need for assistance with toileting during day and night. She also requires assistance with frequent repositioning. This patient is immobile and has continuous needs that cannot be met with a 24-hour live-in PCW (personal care worker), because given the need for frequent repositioning, it is unlikely for the assistant to get five hours daily of uninterrupted sleep during the aide's eight-hour period. Based on the progression of this patient's condition, the proposed increase to PCW (personal care worker) 24 hours/day, split shift is medically necessary to meet this patient's needs for assistance as noted above.