Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident.
Treatment: Increase Personal Care Worker Services 12 Hours Per Day/ 7 Days A Week Totaling 84 Hours/ Week.

The insurer denied the Increase Personal Care Worker Services 12 Hours Per Day/ 7 Days A Week Totaling 84 Hours/ Week.  The denial is overturned.

The patient is a female. She has conditions including CVA (cerebrovascular accident) with residual right sided weakness, cervical and lumbar radiculopathy, and memory loss.  She lives alone in a three-bedroom apartment.  The patient is appealing denial of PCW (personal care worker) services at 12 hours/day, 84 hours/week.  The patient has been approved for 8 hours/day, 56 hours/week.

The assessment performed shows the patient has minimally impaired cognition and functional status; maximal assistance with meal preparation, housework, shopping, bathing, and lower body dressing; extensive assistance with stairs, transportation, personal hygiene, upper body dressing, walking, locomotion, and toileting; limited assistance with managing finances and medication, phone use, bed mobility, and eating. She uses a cane for ambulation. She had a fall when going to the bathroom from the bedroom.  Appeal letter from the patient's provider notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the assessment.  Notes she has limited functioning due to right hand weakness and pain.  She uses a rollator for ambulation.  Notes she is incontinent throughout the day and night.  Provider notes she uses bedside commode when she wakes up in time.

Yes, the Increase Personal Care Worker Services to 12 Hours Per Day/ 7 Days A Week Totaling 84 Hours/ Week is medically necessary.

Medically necessary services are those which are:  1) safe, 2) effective, 3) generally accepted national standard of medical practice, 4) not provided primarily for convenience of the patient or the practitioner, and 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary, because it is consistent with generally accepted national standard of medical practice.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient was approved for 56 PCW (personal care worker) services per week.  The patient is appealing denial of 84 hours per week.  The patient has multiple chronic medical conditions, including right-sided hemiparesis.  Assessment performed shows the patient requires some degree of assistance with all ADLs (activities of daily living) IADLs (instrumental activities of daily living).  She requires extensive to maximal assistance with meal preparation, housework, shopping, bathing, dressing, stairs, transportation, personal hygiene, upper body dressing, walking, locomotion, and toileting.  She is incontinent throughout the day and night.  She does not have informal support.  Appeal letter from the provider is recommending an increase in hours due to weakness, poor functional status, and needs with unscheduled toileting.  This patient requires significant assistance with all ADLs (activities of daily living) and IADLs (instrumental activities of daily living) throughout the entire day.  The approved 56 PCW (personal care worker) hours per week are inadequate to meet the patient's needs as noted above.  The proposed increase of personal care worker hours to 84 hours per week is medically necessary to meet this patient's need for assistance with ADLs (activities of daily living) and personal care.