Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Falls.
Treatment: Personal Care Worker (PCW) services.
The insurer denied Personal Care Worker (PCW) Services: 7 Days per Week, 24 Hours per Day Continuous Care by More than 1 Person - 168 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, glaucoma, urinary retention with urinary incontinence, diabetes mellitus type 2, hyperlipidemia, gait instability, anxiety, and depression who had been assigned Personal Care Worker (PCW). The patient's PCP (primary care provider) noted that the patient had difficulty with walking and had been working with physical therapy but refused to cooperate. The patient had a psychiatry appointment with adjustments in medications. There was a request to increase PCW hours and the patient underwent a universal assessment tool noting the patient was unable to express care goals due to cognitive impairment. The patient was assessed at total assistance with tasks of ordinary housework, managing finances, and shopping while maximum assistance with tasks of meal preparation, managing medication, phone use, transportation, and equipment management. The patient was assessed at extensive assistance with tasks of stairs, bathing, walking, dressing lower body and toilet use while limited assistance with tasks of personal hygiene, dressing upper body, locomotion, transfer toilet, bed mobility, and eating. 

Personal Care Worker (PCW) Services: 7 Days per Week, 24 Hours per Day Continuous Care by More than 1 Person - 168 Hours per Week are medically necessary for this patient. 

There is documentation from the patient's psychiatrist that her mental health condition is worsening and medications prescribed make her more at risk for adverse events overnight. There is documentation that the patient has had a decrease in functional mobility and was not able to follow directions from physical therapy due to her mental health and cognitive issues. The letters from the patient's psychiatrist, PCP, healthcare advocate, and overnight logs indicate that the patient requires more assistance with activities of daily living (ADLs) than was documented in the assessment. The patient requires assistance with all ADLs and Instrumental activities of daily living (IADL). The recent assessment under estimated the patient's care needs. Overnight logs also support continuous services as a live-in PCW would be unable to obtain 5 hours of uninterrupted sleep due to the assistance needs with ADLs in the overnight hours. The increase in PCW hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs. 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, 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.