Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthostatic hypotension, dysarthria and neurogenic bladder

Treatment: Personal care worker (PCW) 3 days per week 14 hours per day (Friday to Sunday) and consumer directed personal assistance services (CDPAS) 4 days per week, 14 hours per day (Monday to Thursday); 98 hours per week

The insurer denied coverage for personal care worker (PCW) 3 days per week 14 hours per day (Friday to Sunday) and consumer directed personal assistance services (CDPAS) 4 days per week, 14 hours per day (Monday to Thursday); 98 hours per week

The denial is upheld
 

This is an adult female with chronic medical problems including orthostatic hypotension, dysarthria and neurogenic bladder. She lives with her spouse in a private residence. The insurer approved personal care worker (PCW) services 3 days per week, 11 hours per day (Friday to Sunday) and 4 days per week, 11 hours per day (Monday to Thursday) of consumer directed personal assistance services (CDPAS); 77 hours per week in total. The patient is requesting personal care worker (PCW) services 3 days per week, 14 hours per day (Friday to Sunday) and 4 days per week, 14 hours per day (Monday to Thursday) of consumer directed personal assistance services (CDPAS); 98 hours per week.

The Uniform Assessment System (UAS) was reviewed. The patient' cognition is described as modified independent. She is reportedly totally dependent to maximal assistance for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is also reported as totally dependent for locomotion and is non ambulatory. Maximal assistance is reportedly needed for bathing, lower body dressing and toilet transfer/use. She reportedly requires extensive assistance for personal hygiene, upper body dressing and bed mobility. Limited assistance is needed for eating. She is able to self-catheterize for bladder continence and is continent of bowel. 

There has been no reported change in the patient's activities of daily living (ADLs) status or reported falls over the prior 90 days. The patient's functional ability is much the same when compared to the previous UAS. The patient's medical condition and functional ability are not at a level or unpredictable as to require the requested personal care worker (PCW) services 3 days per week, 14 hours per day (Friday to Sunday) and 4 days per week, 14 hours per day (Monday to Thursday) of consumer directed personal assistance services (CDPAS); 98 hours per week in total.

The patient may benefit from monitoring for safety; particularly due to her decreased mobility and orthostasis. However, consumer and self-directed personal assistance services for companion care or safety supervision without the direct provision of ADL task assistance is not a covered service. In addition, the patient lives with her spouse who can provide informal care. Based on the enclosed documents reviewed including the medical reports and physical therapy notes, the patient' health and safety can be appropriately provided and maintained at home by the insurer approved personal care worker (PCW) services 3 days per week, 11 hours per day (Friday to Sunday) and 4 days per week, 11 hours per day (Monday to Thursday) of consumer directed personal assistance services (CDPAS); 77 hours per week in total. The patient also has the option of restructuring and flexibly using the 77 hours weekly to better maintain and meet her functional needs as well as correspond to her spouse's reported work schedule.  

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 personal care worker (PCW) services 3 days per week, 14 hours per day (Friday to Sunday) and 4 days per week, 14 hours per day (Monday to Thursday) of consumer directed personal assistance services (CDPAS) services; 98 hours per week is not substantiated.