Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, enlarged prostate, hypertension, gastroesophageal reflux disease (GERD), osteoarthritis, hypercholesterolemia, and spinal stenosis.

Treatment: Personal care worker (PCW) services 7 days per week, 24 hours per day; live in; 91 hours per week.

The insurer denied coverage for personal care worker (PCW) services 7 days per week, 24 hours per day; live in; 91 hours per week.

The denial is overturned.

This male is currently residing in a skilled nursing facility (SNF). He was admitted for short term rehabilitation following hospitalization for COVID 19. The patient previously was living at home alone. He has several medical conditions associated with functional impairment that limits his ability to perform daily activities. Prior to hospitalization, the patient needed help with most daily tasks. His family provided some informal support, but he mostly depended on personal care worker (PCW) services for assistance with instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The Uniform Assessment (UAS) indicated the patient was receiving PCW services 52 hours per week. His functional status declined due to COVID, and he was transferred from hospital to SNF for rehabilitation. In order to ensure safe discharge home, the SNF discharge plan includes 24-hour care, 7 days per week (as noted in the SNF physician's letter of medical necessity). Request was made for increase of PCW services to 24 hours per day, live-in, which was denied. PCW services 52 hours per week were approved. External appeal was requested.

There are several aspects of the patient's medical history that need to be considered when determining the patient's personal care needs. The patient has dementia. The UAS identifies significant cognitive impairment including decision making for daily tasks described as moderately impaired (decisions consistently poor or unsafe, cues/supervision needed at all times); short term and procedural memory problem; difficulty paying attention/easily distracted. For a person with dementia, loss of ability to perform daily activities is an expected consequence as cognitive impairment progresses. In earlier stages of dementia, cognitive decline for IADLs usually precedes ADLs, as IADLs generally require higher level of cognitive function. At the time of the UAS, the patient needed maximal assistance or was totally dependent for most IADLs. It is likely that cognitive impairment was a significant factor in his inability to perform IADLs (in addition to physical limitations). 

MLTC (managed long term care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs throughout the day and night must be considered in the determination of the patient's personal care service hours. Considering the patient's medical history and functional status (based on most recent description in the available SNF records), it is medically necessary for the patient to have assistance for all daily activities when needed throughout the day and night. This includes all household related tasks; meal preparation and service for all meals; medications; bathing daily; personal hygiene and dressing morning/evening; assist/encourage with eating; plus, assistance with tasks that occur at unscheduled and recurring times of the day and night, including toileting/incontinence care and mobility around the home. This level of care and frequency of caregiver assistance is necessary to ensure proper and safe completion of all daily activities; help ensure adequate food and fluid intake; decrease risk of complications from inadequate toileting/incontinence care (e.g., skin damage); help decrease occurrence of falls/injury.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for personal care worker (PCW) services 7 days per week, 24 hours per day; live in; 91 hours per week is overturned. Medical Necessity is substantiated.