Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, hypertension, colostomy, anxiety, major depression

Treatment: Personal Care Worker (PCW) services of 24 hours per day, 7 days per week continuous care by more than 1 person, 168 hours.

The insurer denied coverage for PCW services of 24 hours per day, 7 days per week continuous care by more than 1 person, 168 hours.

The denial is overturned

The patient is a female with a past medical history of Alzheimer's dementia, hypertension, colostomy, anxiety, major depression with manic episodes in young adulthood, vitamin D deficiency, chronic obstructive pulmonary disease (COPD), and frequent falls.

Per the New York State Department of Health's Uniform Assessment System (UAS-NY) dated, the patient is residing in a Skilled Nursing Facility (SNF). She was discharged home.

Needs are: 
-	Total dependence for instrumental activities of daily living (IADLs);
-	Extensive Assistance for personal hygiene, upper body (UB) and lower body (LB) dressing;
-	Limited assistance for walking, locomotion, toilet transfer; 
-	Supervision/Independence for bed mobility;
-	Cognition: There is significant impairment. 
-	Continence: She has a chronic Foley due to retention. She has a colostomy. 

Nighttime needs log shows multiple episodes of emptying the urinary catheter bag. She gets out of bed at times. 

An increase to PCW services of 24 hours per day, 7 days per week continuous care by more than 1 person, 168 hours is being requested. 

The insurer has partially denied coverage for the PCW services of 24 hours per day, 7 days per week continuous care by more than 1 person, 168 hours. 
 
An Independent Consumer Advocacy Network is appealing. In a letter, they explained the patient's medical history and healthcare needs. The patient's multiple medical diagnoses and declining health affect her ability to complete basic activities of daily living and instrumental activities of daily living. The patient requires continuous care to keep her healthy and safe in her home. The patient's family is supportive and involved, but they cannot be assumed to be available to provide assistance. The patient's family is unable to provide informal support. Ms. Luborsky included supporting documentation with her appeal.

The patient is totally dependent for IADLs. The issue here is the level of service needed around the clock, as 24-hour coverage is requested. The patient has significant dementia. She is incontinent but currently has a Foley and a colostomy. She therefore does not require pull-up changes. But the urine bag is emptied several times/night (she cannot do it). There is a potential problem of the colostomy leaking. She needs cuing for ADLs but also needs assistance (limited) with walking. She does get out of bed at night. She has ambulation aides but needs help using them. She needs more than just safety monitoring and supervision.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's assessment of her needs.

The insurer's denial of coverage for the requested Personal Care Worker (PCW) services of 24 hours per day, 7 days per week continuous care by more than 1 person, 168 hours is reversed. Medical necessity is substantiated.