Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 

The insurer denied Personal Care Worker (PCW) service- 7 days per week, 24 hours per day, live in, 91 hours per week. 
The denial is overturned. 

The patient is a male with a past medical history of benign prostatic hyperplasia (BPH), atrial fibrillation on chronic anticoagulation, gastroesophageal reflux disease (GERD), cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), coronary artery disease, hearing loss, hypertension, mild intermittent asthma, hyperlipidemia, urinary incontinence, bowel incontinence, cervical myelopathy, and vitamin B12 deficiency who had been assigned personal care assistance (PCA) services.
The patient underwent another assessment assessing the patient at total assistance with tasks of ordinary housework, managing finances, stairs, transportation, and locomotion while maximum assistance with tasks of meal preparation, managing medication, phone use, bathing, dressing lower body, transfer to the toilet, and toilet use. With tasks of equipment management, personal hygiene, dressing upper body, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. Notes from the assessment stated the patient used a wheelchair and scooter, had bowel and bladder incontinence, and had informal help from a child/child in law. The insurer sent final adverse determination denial notice stating they were not changing the decision to partially deny services. 

At issue is the medical necessity of Personal Care Worker (PCW) service- 7 days per week, 24 hours per day, live in, 91 hours per week. 

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

The requested health service/treatment of Personal Care Worker (PCW) service- 7 days per week, 24 hours per day, live in, 91 hours per week is medically necessary for this patient. 

There is documentation from the patient's neurologist and primary care physician of worsening cognitive and functional status. There is documentation from the plan's assessments of worsening of functional status with increased need of assistance with tasks of managing finances, managing medication, phone use, stairs, shopping, transportation, bathing, personal hygiene, dressing lower body, walking, locomotion, transfer to the toilet, toilet use, and bed mobility. There is documented medical necessity for increased PCA services by the patient's medical provider(s). The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has urinary and bowel incontinence within need for assistance outside of the currently assigned services and in the overnight hours.  The plan assumed, incorrectly, the patient has informal help for all of the hours outside of currently approved services. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 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 his own home. 

Therefore, the requested health service/treatment of Personal Care Worker (PCW) service- 7 days per week, 24 hours per day, live in, 91 hours per week is medically necessary.