Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, hemiplegia affecting left side, subdural hemorrhage,

Treatment: 5 days per week, 8 hours per day (Monday to Friday), 56 hours per week, Personal Care Worker (PCW)

The insurer denied coverage for 5 days per week, 8 hours per day (Monday to Friday), 56 hours per week, Personal Care Worker (PCW). The denial is reversed. 

This patient is a female who lives with family. She had an extensive medical history and substantial functional impairment and receives assistance with daily activities from personal care worker (PCW) when a particular family member is at work (8 hours per day, 5 days per week) and from family during hours PCW is not present. The patient was enrolled in another health plan last year; and as per law, when she changed to current health plan she received the same services for 90 days as she was receiving prior to the change in health plan. Following a second assessment the health plan reduced the patient's PCW hours from 8 to 7 hours per day, 5 days per week. Care management notes from the health plan indicate the daughter did not agree with the change, as her mother cannot be alone between the time the PCW leaves and the daughter arrives home from work. The patient's son requested an external appeal.

As per the UAS, the patient's functional status indicates significant impairment of mobility related activities. For IADLs, the patient depends on caregiver help for all household related tasks (maximal assistance). She also needs maximal assistance for managing medications and finances and extensive assistance for phone use. For ADLs, she needs extensive or limited assistance for all except bed mobility (independent setup help). A copy of a previous UAS was not provided for review, but in the UAS that was provided noted that there was no change in ADL status or self-sufficiency in previous 90 days.

Elderly people often have multiple health problems that result in various symptoms and limitations of function. The cumulative effect of these problems can result in substantial decline in ability to perform daily activities. The UAS and physician office note include several medical conditions that most likely contribute to patient's functional decline.

The UAS reports patient has chronic pain in her back and hands. The physician also indicates numbness due to neuropathy. Arthritis and neuropathic symptoms affecting the hands have a significant adverse effect on the ability to perform daily activities requiring upper extremities (e.g. bathing, personal hygiene, dressing, toileting household chores). Back pain affects ambulation and transfers (per UAS patient has unsteady gait, difficulty standing up unassisted). Arthritis is a frequent cause of functional impairment in older people resulting in dependence on caregiver assistance for daily activities. 
All of these problems contribute to the patient's functional decline and a high risk situation for falls/accidents. The patient has multiple risk factors for falls including: arthritis, dizziness, unsteady gait, poor balance, chronic pain, incontinence, cognitive impairment, h/o falls, advanced age, use of medications associated with risk for falls (including antihypertensive drugs, antidepressant).

Personal Care Worker services 5 days per week, 8 hours per day are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage to maintain service at 5 days per week, 8 hours per day (Monday to Friday), 56 hours per week, Personal Care Worker (PCW) is reversed.  The medical necessity is substantiated.