Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope.
Treatment: Personal care worker (PCW) 24 hour Live in, 7 days a week.
The insurer denied Personal care worker (PCW) 24 hour Live in, 7 days a week.
The determination is overturned.


This is a patient with a medical history notable for ambulatory difficulty, history of syncope, coronary artery disease, chronic obstructive pulmonary disease (COPD), and fall risk. The patient is currently approved for 7 hours per day, 5 days per week and 3 hours per day, 2 days per week (41 hours per week; reduced hours two days per week due to social daycare) of personal care services. The patient and his care team requested an increase to 24 hours per day live-in, 7 days per week and this request was denied by the health plan.
A letter of support for this appeal was provided by the patient. The letter states that when his aide leaves, he "cannot safely walk to the bathroom." He has a history of trying to go by himself and falling. He also has a stomach medication and sometimes vomits and/or requires medication in the night and requests assistance for this. He lives alone and does not have family assistance available.
Notes from the treating neurologist were provided for review. The notes state that he has had "significant worsening in the last few months. Difficulty walking. He needs assistance with daily activities and ambulation...He needs assistance 24 hours per day / 7 days per week." Given his age and comorbidities, medical management and physical therapy were recommended with avoidance of surgery despite evidence of myelopathy.
The patient was hospitalized for worsening dizziness. This was felt to be secondary to either a transient ischemic attack (TIA) or labyrinthitis. He was discharged home with routine follow up.
Physical therapy notes were provided for review. He requires limited assistance for moving to a seated position or chair. He requires maximum assistance for bathing. He requires extensive assistance for toilet transfers, dressing, and other activities of daily living (ADLs). He was noted to have a significant decline in his functioning. His long term goals were to be able to perform personal hygiene tasks independently.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to be alert and responsive with periods of forgetfulness. He is able to call 911 in an emergency. From a functional standpoint, he requires maximal assistance for stairs, housework, and meal preparation. He requires extensive assistance for managing medications, shopping, and transportation. For his ADLs, he requires extensive assistance for most, including: bathing, hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. He requires limited assistance for bed mobility and eating. He walks with a walker with an unsteady gait and fair balance. He is noted to be weaker after his hospitalization. He is incontinent of urine with no control present and uses pull ups. He is continent of stool. Compared with an assessment from one month prior (before his hospitalization), he showed a functional decline in multiple ADL's including walking, locomotion, and toilet transfer. At issue is the medical necessity of a personal care worker (PCW) 24 hour Live in, 7 days a week.

The requested health service of personal care worker (PCW) 24 hour Live in, 7 days a week is medically necessary for this patient.
The patient has had a functional decline as reflected in the Uniform Assessment System (UAS) and as noted by his physician. He requires hands on assistance for all ADLs and Instrumental activities of daily living (IADLs). He is no longer able to toilet independently. He is incontinent of urine and uses pull-ups which require assistance for changing. Due to the unscheduled nature of his personal care needs, a task tool cannot be relied on to accurately predict the patient's true need. He is continuing to work with physical therapy, but at this time does not have the strength to complete ADLs such as toileting without assistance. Failure to assist him with these functional needs can lead to falls (which the patient states has already happened). Failure to change his pull up in a timely manner could lead to infection and/or skin breakdown.