Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, legal blindness, arthritis, anemia, diabetes, and kidney disease.
Treatment:  Increase Personal Care Worker (PCW) Service To 7 Days Per Week, 24 Hours Per Day Continuous Care By More Than One Person. A total of 168 Hours Per Week.

The insurer denied: Increase Personal Care Worker (PCW) Service To 7 Days Per Week, 24 Hours Per Day Continuous Care By More Than One Person. A total of 168 Hours Per Week.  The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, legal blindness, arthritis, anemia, diabetes, and kidney disease. She lives alone. Denial of increase personal care worker (PCW) service to 7 days per week, 24 hours per day continuous care by more than one person for a total of 168 hours per week is being appealed. The health plan approved 7 days per week, 24 hours per day, live in, for a total of 91 hours per week. An appeal statement from the patient's grandchild and the medical records note that the patient has several chronic conditions. She has a history of several falls. She was admitted after a fall, with worsening dementia, and deep vein thrombosis. She is homebound. She requires maximal assistance or total dependence with all ADLs (activities of daily living), including turning/repositioning every 2 hours. She uses a wheelchair for ambulation. She is incontinent and requires assistance with 
toileting and hygiene. This patient's needed assistance and need for turning/repositioning and toiling are support by logs showing care provided.

The requested Increase Personal Care Worker (PCW) Service To 7 Days Per Week, 24 Hours Per Day Continuous Care By More Than One Person. A total of 168 Hours Per Week is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase personal care worker (PCW) service to 7 days per week, 24 hours per day continuous care by more than one person for a total of 168 hours per week is being appealed. The health plan approved 7 days per week, 24 hours per day, live in, for a total of 91 hours per week. This patient has multiple chronic conditions. She was admitted after a fall, with worsening dementia, and deep vein thrombosis. She lives alone. Medical records show that the patient needs assistance with all ADLs (activities of daily living). She is incontinent. Logs support the patient receiving continuous care that includes assistance with toileting and turning/repositioning. The information provided shows that this patient has significant limitations in functioning that that will not give an aide five hours daily of uninterrupted sleep during the aide's shift. The requested increase in PCW (personal care worker) from live-in to split shift is medically necessary.