Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Functional Decline.
Treatment: Home Health Care.
The insurer denied Personal Care Worker (PCW) services; 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person.
The denial is overturned. 

The patient is a female with a past medical history of dementia, chronic constipation, bladder incontinence, bowel incontinence, depression, and glaucoma who had been assigned personal care assistance (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week. The patient's primary care physician (or provider) (PCP) provided a letter stating the patient required an increase in home care services as the patient's functional status had declined and the patient's son who was ill and frail himself was no longer able to provide the level of care that the patient required. The letter also stated the patient had recently contracted coronavirus 2019 (COVID-19) and this infection worsened her functional mobility with the inability to stand on her own and the patient was essentially bedbound. The letter also stated the patient required assistance to turn in bed and must be transferred by a home attendant to a wheelchair for mobility related activities of daily living (ADL)s. The provider noted the patient required spoon feeding and assistance with drinking. The provider stated the patient was bedbound and too weak to perform her own bed mobility and the provider noted the patient required frequent turning to prevent skin breakdown both day and night. The patient's PCP also noted the patient required assistance with toileting which was unscheduled both day and night and the patient was no longer able to independently transfer from bed/wheelchair to toilet/commode.
At issue is the medical necessity of Personal Care Worker (PCW) services; 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Personal Care Worker (PCW) services; 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person is medically necessary for this patient.
There is documentation of worsening cognitive and physical functioning following COVID-19 infection to a point that the patient was bedbound, requiring a Hoyer lift for transfers as well as requiring assistance with feeding and drinking. There is also documentation from the patient's PCP that the patient requires frequent turning and repositioning overnight, and that the patient's son is not able to provide informal care, as previous, due to his own medical conditions. The patient's care needs cannot be met solely with adaptive equipment and medical supply as the insurer recommended in denial letters. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL)s. The patient has overnight care needs that would not allow a PCA worker to obtain at least 5 hours of uninterrupted sleep. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, 7 days/week, continuous care by more than one person, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Therefore, the requested health service/treatment of Personal Care Worker (PCW) services; 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person is medically necessary.