Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis. 
Treatment: Home Health Care. 

The insurer denied Personal Care Worker (PCW) Service: 7 Days per Week, 24 Hours per Day Continuous Care by More Than One Person [168 Hours per Week]. The health plan's determination is overturned. 

The patient is a female with past medical history of multiple sclerosis, bladder incontinence, bowel incontinence, anxiety, depression, cerebrovascular accident (CVA), wheelchair-bound status, age-related cognitive decline, seizure disorder, osteoarthritis, and gastroesophageal reflux disease (GERD) who had been assigned PCW (personal care worker) services assessing the patient at total assistance with ordinary housework while maximum assistance with meal preparation, stairs, shopping, transportation, equipment management, bathing, dressing lower body, locomotion, and toilet use. With tasks of managing finances, managing medication, phone use, personal hygiene, dressing upper body, walking, transfer toilet, bed mobility, and eating the patient was assessed at extensive assistance. 

Personal Care Worker (PCW) Service: 7 Days per Week, 24 Hours per Day Continuous Care by More Than One Person [168 Hours per Week] are medically necessary for this patient. 

There is documentation of the patient's worsening functional status specifically moderate assistance with bed mobility and transfers per physical therapy. In addition, there is an overnight care log noting the patient's needed assistance with activities of daily living (ADL) at least every 2-3 hours. Additional notes from the patient's primary care physician (PCP) indicate the patient was wheelchair-bound by the summer. The patient had a change in social circumstance in which, the patient's daughter who provided informal help, was unable to do so at the same level as previous. In addition, the insurer's own notes stated that the patient was up 5 times per night, was unable to change her diapers, needed help obtaining a blanket, food, and water. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The plan assumed incorrectly that the patient had informal help outside of all of the hours of currently assigned PCW services. There are documented overnight care needs which would not allow a PCW to obtain 5 hours of uninterrupted sleep. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCW services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCW services 24 hours/day, continuous care by more than one person, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.