Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic neuropathy, seizure disorder, lumbar spine stenosis, lumbar radiculopathy, coronary artery disease

Treatment personal care worker (PCW) services of 12 hours per day, 7 days per week for a total of 84 hours per week

The insurer denied coverage for personal care worker (PCW) services of 12 hours per day, 7 days per week for a total of 84 hours per week

The denial is overturned

This patient has an extensive medical history associated with functional impairment and needs assistance with most daily activities. The patient lives alone. The UAS [Uniform Assessment System] identified 2 informal caregivers, but it appears their availability to provide assistance to the patient is limited. It appears the patient primarily relies on personal care worker (PCW) services for help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient had been approved for PCW services 49 hours per week. The patient requested increase of PCW to 84 hours per week, 12 hours per day, which was denied but PCW services were increased to 50 hours per week. An external appeal was requested.

The patient has multiple sources of pain affecting most ADLs [activities of daily living]. The UAS indicates patient has osteoarthritis. The physician's letter indicates knees and hips are affected. She also has meniscus tear of the knee. Diagnosis of gout is included in the UAS; patient is taking allopurinol, but specific joints affected, and frequency and severity of symptoms are not reported in the available records. The patient has lumbar spinal stenosis with radiculopathy which can cause lower back pain and pain radiating down the leg. These conditions affecting the lower extremities and lower back can adversely affect all aspects of mobility. The patient needs varying degrees of assistance with walking, transfers, stairs. The patient needs assistance with ADLs such as bathing, lower body dressing, toilet transfer which also depend on lower extremity function. 

The patient has multiple symptoms including pain, fatigue, dyspnea, dizziness. Each of these symptoms can limit ability to perform daily activities. When they occur together on a chronic basis, the effect can be debilitating for an older person; the effort to perform routine tasks becomes a burden, resulting in low activity tolerance; and can contribute to depression and anxiety (patient is taking mirtazapine, clonazepam). Providing caregiver assistance throughout the day for ADLs and household related tasks can facilitate safe and effective completion of daily activities and help relieve some of the patient's physical and mental stress associated with performing these tasks. 

Considering the patient's medical history and functional status as noted in the available records, it is apparent that the patient needs assistance for all ADLs and IADLs. Therefore, it is medically necessary, and in the patient's best interest, to have a caregiver present throughout the day to assist with daily activities. The patient needs assistance for IADLs and ADLs that occur at various scheduled and unscheduled times throughout the day. This includes routine household tasks, and preparation/service of all 3 meals; assist with eating; routine morning and evening ADLs (e.g., bathing, dressing, personal hygiene); and unscheduled/recurring activities, including toileting related tasks/incontinence care; mobility around the home (transfers, walking). Without adequate assistance, the patient is at risk for adverse health and safety events, e.g., falls/injury, nutritional decline, dehydration, aspiration, skin damage due to incontinence.

As per the UAS, the patient has two informal caregivers, but the number of hours provided in the previous 3 days was noted as 0. Considering the request for increase of PCW services is for 84 hours per week, 12 hours per day, it is reasonable to conclude that there are no informal caregivers who can provide care during that period of time each day.  Assistance from informal caregivers is voluntary as per NYS (New York State regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day.

Personal Care Worker services 7 days per week, 12 hours per day, 84 hours per week is medically necessary. 

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 of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical Necessity is substantiated.