Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, Osteoarthritis of the knees, Arthritis of the cervical and lumbar spine, Right wrist fracture
Treatment: Personal Care Worker (PCW) Service - 12 hours per day, 7 days per week, totaling 84 hours per week
The insurer denied coverage for Personal Care Worker (PCW) Service - 12 hours per day, 7 days per week, totaling 84 hours per week.
The denial is overturned. 

This is a female patient who had a fall that resulted in a right wrist fracture. The patient was living alone prior to the fall but due to her need for substantial assistance with daily activities immediately after the fall and fracture, she stayed with her daughter for a while.  The patient was receiving personal care worker (PCW) services 36 hours per week.  A request was made for an increase to 84 hours per week, which was denied; but PCW hours were increased to 42 per week. The daughter provided some assistance when the aide was not present; but the daughter indicated she was unable to have her mother stay long term with her. Based on documentation, it appears the patient is in her own home again, living alone with PCW 42 hours per week. The daughter requested PCW 12 hours per day, 84 hours per week.

The most recent Uniform Assessment System (UAS) documentation is two weeks after the patient fractured her wrist. The patient had cast in place and had severe limitation of use of her right arm. The functional status report for instrumental activities of daily living (IADLs) from the UAS report indicates the patient was totally dependent or needed maximal assistance for household related tasks, shopping, transportation; and extensive assistance for medications. For activities of daily living (ADLs), the patient needed maximal or extensive assistance for all activities, except bed mobility (limited assistance). 

The patient's history includes Parkinson's disease, osteoarthritis of the knees, and arthritis of the cervical and lumbar spine. Considering the patient's medical history and functional impairments associated with her medical conditions, it is medically necessary and in the patient's best interest to have a caregiver present for a more extended period of the day to assist with routine IADLs and ADLs (including evening meal and ADL care), and assistance with mobility (walking, transfers) and toileting related tasks, which occur at various unscheduled times throughout the day. The patient's daughter reported that she is unable to assist her mother. The UAS report did not identify any other informal caregivers. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When there are no informal caregivers who can provide necessary care on a consistent basis, then personal care services are indicated to provide assistance with all necessary daily activities, including ADLs that occur throughout the day.

There is still some concern about the patient's need for assistance at night. The fall that caused the wrist fracture occurred at night. The amount of PCW hours that can be recommended from this review is limited by the number of hours requested, i.e. 84 hours per week. Re-assessment will determine whether this plan adequately meets the patient's daily care needs.

Personal Care Worker Service, 12 hours per day, 7 days per week, total of 84 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment.

The carrier's denial of coverage for PCW Service - 12 hours per day, 7 days per week, totaling 84 hours per week is overturned. The medical necessity is substantiated.