Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Cerebral atherosclerosis with chronic cerebral ischemia
 
Treatment: Personal Care Worker (PCW) Services, 24 hours (live-in)

The insurer denied coverage for Personal Care Worker (PCW) Services, 24 hours (live-in). The denial is reversed. 

This patient is a male who lives alone with diagnoses that included cerebral atherosclerosis with chronic cerebral ischemia, coronary artery disease (CAD), depression/anxiety, dizziness/vertigo, unsteadiness with increased fall risk, back pain, difficulty walking. The patient's condition recently worsened since late-2019. He developed atrial fibrillation, and diagnosed with acute pericarditis with effusion. He became extremely weak and fragile. He was diagnosed with stage III squamous cell carcinoma of lung and requires immunotherapy. He lives alone. With severe weakness and unsteadiness he has high risk for falls and is on anti-coagulation. He has shortness of breath and chest pain. He needs assistance with activities of daily living (ADL) and instrumental activities of daily living (IADL). He needs increased HHA hours.

The patient's previous UAS was done late-2019. Comparison of both assessments indicates patient has had significant functional decline. IADLs: stairs and transportation declined from limited assistance to maximal assistance. ADLs: substantial decline was noted for walking/locomotion from independent setup help to extensive assistance; toilet transfer and toilet use declined from independent setup help to limited assistance. Other symptoms developed or worsened: gait is more frequently unsteady; fatigue is worse; no dyspnea was noted; dyspnea occurs with normal daily activities.

It is not unusual for a person of advanced age to experience rapid functional decline following an acute medical event. However, the ability to recover to the previous level of function is dependent on several factors, including patient's general health status, caregiver support, mental status of patient (cognition and mood). The late-2019 UAS indicates the patient needed limited help with ADLs (prior to acute illness in late-2019). When the patient had no acute health problems, it appears he was compensating reasonably well with his chronic medical conditions. However, in his debilitated state, his previously manageable chronic medical conditions may now present greater obstacles to routine daily activities.

If he had adequate informal support at home, this may be a reasonable plan; but he lives alone, and 5.5 hours of help per day is not sufficient for a person with substantial need for assistance for mobility related daily activities. It would be enough of a concern if the patient's functional decline was all due to an acute illness. However, the patient has a new and serious problem. He was diagnosed with lung cancer. Current symptoms of fatigue and dyspnea may be associated with this diagnosis. Based on the information provided for review (medical records, UAS, care management notes, physician letters), it is apparent that the patient has experienced a substantial decline in his medical and functional status, and it is medically necessary for the patient to have caregiver support in his home throughout the day and night to assist with ADLs that occur throughout the day and night (i.e. transfers, walking, toileting/incontinence care). In the absence of informal caregivers who can provide the necessary care, then it is medically necessary for PCW services to provide assistance.

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

Based on the above, the medical necessity for Personal Care Worker (PCW) Services, 24 hours (live-in) is substantiated.  The insurer's denial is reversed.