Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic Headaches, Diabetes.
Treatment:  Personal care worker (PCW) services 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week.

The insurer denied coverage for personal care worker (PCW) services 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week.  The denial is upheld.

This is a patient with chronic medical problems including headaches, hypertension and diabetes. The patient lives alone in a 1-bedroom apartment.  The patient requested an increase in personal care worker (PCW) services from 38 hours/week to 168 hours/week; 24 hours/day, 7 days/week; continuous care by more than 1 person that was denied by the insurer, leading to an external review.  

The Uniform Assessment System (UAS) report is reviewed.  The patient's cognition is described as modified independent.  The patient reportedly requires maximal assistance to total dependence for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing and lower body dressing.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing and toilet transfer/use.  Limited assistance is reportedly needed for eating, bed mobility, locomotion and ambulation.  The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel.  The patient's ability to perform activities of daily living (ADLs) and self-sufficiency has reportedly declined over the prior 90 days.   

The patient's medical condition and physical limitations are not at a level or unpredictable as to require increasing PCW services to 24 hours/day, 7 days/week (168 hours/week).  The letters from the patient's treating physicians describing their clinical condition and recommending increase PCW services 168 hours/week were reviewed. There was no documented functional assessment or clinical evidence of functional incapacity.  The physical therapy notes were also reviewed and demonstrates a level of increased functional mobility when compared to the UAS report described earlier.  According to the physical therapist, the patient required only supervision to independence for transferring and ambulating indoors with the use of a rolling walker.  Dressing and bathing were also described as supervision level.   The visiting nursing notes were also reviewed, which document the provision of local wound care for bilateral heel pressure ulcers.  

The reviewer would agree the patient may benefit from additional monitoring for safety; particularly due to her reported weakness and falls risk.  However, PCW services for companion care or safety supervision (e.g., dementia, wandering, weakness, falls risk) without the direct provision of ADL task assistance is not a covered service.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved PCW services 38 hours/week and visiting nursing services as needed.   

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in personal care worker services to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week is not substantiated.