Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic respiratory failure with hypoxia, Osteoarthritis. 
Treatment: Increase in Personal Care Worker (PCW) services from 7 days per week, 6 hours per day; 42 hours per week to 7 days per week, 12 hours per day 84 hours per week. 

The insurer denied coverage for increase in Personal Care Worker (PCW) services from 7 days per week, 6 hours per day; 42 hours per week to 7 days per week, 12 hours per day 84 hours per week. 

The denial is overturned. 

The patient is a patient seeking coverage for an increase in personal care worker (PCW) services from 7 days per week, 6 hours per day; 42 hours per week to 7 days per week, 12 hours per day; 84 hours per week. 

The uniform assessment indicated that the patient lived in a private home/apartment/rented room.  The patient lived alone.  There was minimal impairment in cognitive skills.  In specific situations, decisions would become poor or unsafe.  The patient was often understood and often understood others.  There was minimal difficulty with hearing.  The patient's vision was adequate.  The patient required maximal assistance with meal preparation, ordinary housework, managing finances, and shopping.  The patient walked with the use of an assistive device.  The patient was observed walking and transferring utilizing the rollator and contact guard assistance.  The patient was frequently incontinent of bladder.  There was dyspnea with moderate activity.  There was moderate fatigue.  The patient complained of mild pain. 

Two months later, the patient was seen for a house visit.  The patient was homebound.  The patient reported that since Friday evening, their oxygen concentrator had not worked.  The patient had been without oxygen since Friday night.  The patient reported feeling lightheaded earlier in the morning.  The patient did not want to go to the hospital due to a prior bad experience at the hospital.  The patient was awaiting a technician's arrival to address the oxygen concentrator.  The patient's oxygen saturation was in the mid-80s.  There was a request for assistance in getting more home health care hours.  The provider felt that the patient would benefit from 24-hour home care services.  On the exam, there was dyspnea while sitting in a recliner chair.  Upon exertion, the patient paused while speaking.  

Per the cited references, personal care services must be essential to the maintenance of the patient's health and safety in their home and be based on an assessment of the patient's needs for the service in accordance with guidelines.  Based on the provided documentation, an increase in personal care services is supported as medically necessary for the patient.  The patient has significant limitations in ambulation and requires extensive assistance for transfers, activities of daily living, and instrumental activities of daily living.  The patient is also noted to have incontinence.  The patient's needs cannot safely be met at the current provided service hours.  Without an increase in hours, the patient is at risk of hospitalization and need for higher level of care.  To ensure that the patient is able to continue to live at home and participate in the community, an increase in personal care worker services is supported as medically necessary.  

Based on the above, the insurer's denial must be reversed. The health care plan did not 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 (PCW) services from 7 days per week, 6 hours per day; 42 hours per week to 7 days per week, 12 hours per day 84 hours per week services is substantiated.