Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, heart failure, osteoporosis, anemia, hyperlipidemia and pain
Treatment: Increase Personal Worker (PCW) Services to 7 Days Per Week, 24 Hours Per Day Continuous Care By More Than 1 Person; A total 168 Hours Per Week
The insurer denied Increase Personal Worker (PCW) Services to 7 Days Per Week, 24 Hours Per Day Continuous Care By More Than 1 Person; A total 168 Hours Per Week.
The denial is overturned.

The patient is an elderly female. Her conditions include osteoarthritis, heart failure, osteoporosis, anemia, hyperlipidemia and pain. Denial of increase personal worker (PCW) services to 7 days per week, 24 hours per day continuous care by more than 1 person for a total 168 hours per week is being appealed. The health plan approved 7 days per week, 10 hours per day for a total of 70 hours per week.

Uniform Assessment System (UAS) evaluation completed 3 months ago shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, bathing, and dressing; and extensive assistance with phone use, personal hygiene, dressing, walking, locomotion, toileting, bed mobility, and eating. The patient has bowel and bladder incontinence. Compared to UAS evaluation completed last year, there has been a decline with managing finances and medications, phone use, dressing, walking, locomotion, bed mobility, bathing, and eating. An appeal statement notes that there has been a functional and cognitive decline over the past few months. The patient's conditions further deteriorate after a fall 3 months ago. She requires assistance with all ADLs (activities of daily living). She has incontinence and has nighttime needs for going to the bathroom and cannot transfer out of the bed without assistance. She is temporarily living with her daughter but will return to her apartment, where she lives alone. She has limited informal support. Clinical progress notes state that the patient is homebound and debilitated. She requires 24-hour supervision and is unsafe to be left alone. She has been staying with her daughter since the fall. A letter from the patient's provider notes that the patient has chronic and progressive conditions.

She has had multiple falls, especially when getting up for the bathroom at night. She requires assistance and prompting with ADLs (activities of daily living). She needs to be changed frequently during the day and night after toileting. She is medically stable and able to remain safe in her home as long as she has available assistance throughout the day and night.

The Increase Personal Worker (PCW) Services to 7 Days Per Week, 24 Hours Per Day Continuous Care By More Than 1 Person; A total 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 worker (PCW) services to 7 days per week, 24 hours per day continuous care by more than 1 person for a total 168 hours per week is being appealed. The health plan approved 7 days per week, 10 hours per day for a total of 70 hours per week. This patient has multiple chronic conditions, including recent hospitalization after a fall. Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient requires assistance with all ADLs (activities of daily living). She is incontinent of bowel and bladder. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with managing finances and medications, phone use, dressing, walking, locomotion, bed mobility, bathing, and eating. The appeal statements support the patient is dependent with all ADLs (activities of daily living) and requires frequent assistance with toileting, transfers, and ambulation. She has needs for assistance throughout the day and night. Her physical and cognitive functioning have declined since a fall 3 months ago. The information provided supports that the patient has continuous needs. Her needs cannot be met with the approved PCW (personal care worker) 70 hours per week.