Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Age-related physical debility. 
Treatment: Personal care worker (PCW) service 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person. 

The insurer denied coverage for PCW service 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person. 

The denial is overturned. 

 This is an elderly patient who lives alone and needs assistance with all daily activities due to functional impairment associated with several medical conditions. The Uniform Assessment System (UAS) identifies one informal helper who provides some assistance with instrumental activities of daily living (IADLs). The patient primarily depends on PCW services for assistance with activities of daily living (ADLs) and IADLs. The patient was receiving PCW services 56 hours per week. The patient (via designee) requested PCW services 24 hours per day, continuous care, 168 hours per week, which was denied; but the insurer increased PCW services to 24 hours per day live-in, 91 hours per week. 

The records indicate the patient has vascular dementia. 

The UAS reports patient is in bed or in wheelchair during the day. As per the UAS, the patient has history of cerebral infarction affecting right (dominant) side, described as hemiparesis and hemiplegia. As per the UAS, the aide reported that the patient can barely support herself during transfers and needs complete weightbearing from the aide.

There are no activity logs provided for review that describe the timing of the patient's toileting/incontinence care needs through the day and night. However, the available information indicates the patient has frequent incontinence (bladder and bowel); she is dependent on caregivers for all toileting/incontinence care; and needs help with toileting/incontinence 2-3 times per night. These circumstances are not conducive to a 5 hour uninterrupted sleep period for a live-in aide every night. 

The patient has history of falling. She is unable to walk and needs maximal assist to transfer from the bed or wheelchair. It is very likely she would fall if she attempted to get up from bed unassisted. 

Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present through the day and night to assist with all routine daily activities (including all meals, household tasks, medications, bathing, dressing, personal hygiene); and with activities that occur at unplanned and recurring times through the day and night (transfers, wheelchair mobility, toileting/incontinence care, repositioning, assist with pain relief as needed). 

Due to the volume and frequency of ADL and IADL tasks during daytime/evening hours, it does not appear an aide can sleep for 5 uninterrupted hours during this time period each day. The patient also needs assistance at night. Based on the available information, frequency of care at night does not appear to be compatible with a 5 hour period of uninterrupted sleep for an aide every night. The tasks and frequency of care needed at night is to help prevent adverse health and safety events; and to maintain patient comfort.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in personal care worker (PCW) service from 7 days per week, 8 hours per day, 56 hours per week to 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person is substantiated.