Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, hypertension, dizziness/vertigo, hypercholesterolemia, diabetes mellitus (DM) type 2

Treatment:
The insurer has denied coverage for the PCW [personal care worker] services of 12 hours per day, 5 days per week, and 11 hours per day, 2 days per week

The insurer denied coverage for the PCW services of 12 hours per day, 5 days per week, and 11 hours per day, 2 days per week.

The denial is overturned.

The patient is a homebound female with history of (h/o): coronary artery disease, hypertension, dizziness/vertigo, hypercholesterolemia, diabetes mellitus (DM) type 2, severe constipation, urinary incontinence, gastroesophageal reflux disease (GERD), osteoarthritis, impaired balance, worsening of unsteady gait, Parkinson's disease. Patient cannot take care of herself. Consider increase of home care hours due to medical problems and severe difficulty ambulating at home.

The Uniform Assessment System (UAS) indicates patient is oriented to person, place, and time; some forgetfulness noted, but no significant memory impairment identified. Decision making for daily tasks was noted as some difficulty in new situations only. There were no mood or behavioral problems identified. It appears that the patient's functional impairment with daily activities is primarily due to physical functional impairment. 

Functional impairment in older people is often due to cumulative effect of multiple medical conditions, plus economic and social circumstances (e.g. caregiver support). The following includes some possible contributing factors to the patient's difficulty with daily activities: 
The patient needs extensive assistance with toileting related tasks. Considering her difficulty with mobility (unsteady gait, dizziness, poor balance), the first obstacle is getting to the toilet or commode. She needs weight-bearing assistance with transfers and walking to reach the bathroom or commode; and then weight-bearing assistance to transfer on/off the toilet/commode. 

The Uniform Assessment System (UAS) indicates diagnosis of functional urinary incontinence. There may also be other causes; but considering the patient's impaired mobility, it is likely that delay (or inability) in reaching the toilet or commode is a significant factor causing urinary incontinence during the day and night. Considering the extensive assistance the patient needs for toileting, lower body dressing, bathing, it is likely that she needs assistance with incontinence care. 

The request for 12 hours of assistance on some days and 11 hours of assistance for other days suggests the reason for the difference is due to informal caregiver availability. It appears the family is able to provide some informal support during the other 12 or 13 hours of the day (though the extent of informal service is not known). As per NYS regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care when needed on a regular basis, then personal care services are indicated to provide assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) when needed throughout the day. 

Without knowing the extent of informal caregiver services, there is still some concern for the nighttime hours when the patient needs toileting and/or incontinence care, or other reasons that may result in the patient getting out of bed during the night. 

Personal Care Worker services 12 hours per day, 5 days per week, and 11 hours per day, 2 days per week is medically necessary. The health care plan did not act reasonably, with sound clinical judgment, or in the best interests of the patient.

The insurer's denial of coverage for the requested Personal Care Worker (PCW) Services of 12 hours per day, 5 days per week, and 11 hours per day, 2 days per week is reversed. Medical necessity is substantiated.