Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer, asthma, renal insufficiency, morbid obesity, osteoarthritis, spinal stenosis, and dementia. 
Treatment: Increase in Personal Care Worker (PCW) services from 7 days per week, 11 hours per day, 77 hours per week, to 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week. 
The insurer denied: Increase in Personal Care Worker (PCW) services from 7 days per week, 11 hours per day, 77 hours per week, to 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week. 
The denial is overturned. 

The patient is an elderly female. Her medical conditions include breast cancer, asthma, renal insufficient, morbid obesity, osteoarthritis, spinal stenosis, and dementia. Denial of Increase in personal care worker (PCW) services from 7 days per week, 11 hours per day, 77 hours per week, to 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week is being appealed. The health plan approved for 7 days per week, 24 hours per day; live-in; 91 hours per week. 
Uniform Assessment System evaluation completed 5 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, phone use, bathing, lower body dressing, and toilet use; extensive assistance with personal hygiene, upper body dressing, walling, locomotion, toilet transfer, and bed mobility; and limited assistance with eating. The patient is incontinent of bowel and bladder. A letter from the patient's provider notes the patient is homebound and has multiple medical conditions. Her medical conditions are worsening, and she has urinary incontinence. She needs home care, as well as assistance with diaper changes. A letter from the patient's daughter notes that the patient needs frequent diaper changes and assistance with toileting due to cognitive and physical limitation. She has unscheduled needs that prevent an aid from getting 5 hours of uninterrupted sleep. There are night logs showing assistance with toileting every 2 to 3 hours. 

The Increase in Personal Care Worker (PCW) services from 7 days per week, 11 hours per day, 77 hours per week, to 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week 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. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of Increase in personal care worker (PCW) services from 7 days per week, 11 hours per day, 77 hours per week, to 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week is being appealed. The health plan approved for 7 days per week, 24 hours per day; live-in; 91 hours per week. This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient requires assistance with all ADLs (activities of daily living). She is incontinent of bowel and bladder. The appeal statements support the patient is dependent with all ADLs (activities of daily living). Night logs show the patient requires frequent assistance with toileting and transfers every 2 to 3 hours. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed PCW (personal care worker) of 168 hours per week is medically necessary.