Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, diabetes, anemia, and osteoarthritis.
Treatment: Increase Personal Care Worker (PCW) to 7 Days per Week, 24 Hours per Day, Continuous Care by More than One Person - a Total of 168 Hours per Week.
The insurer denied: Increase Personal Care Worker (PCW) to 7 Days per Week, 24 Hours per Day, Continuous Care by More than One Person - a Total of 168 Hours per Week.
The denial is overturned.

This elderly female patient has multiple medical conditions including dementia, hypertension, diabetes, anemia, and osteoarthritis. She lives alone. This is an appeal for denial of increase personal care worker (PCW) to seven days per week, 24 hours per day, continuous care by more than one person a total of 168 hours per week. The health plan approved an increase from 49 to 63 hours per week.  

Uniform Assessment System evaluation completed earlier this year shows moderately impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, and lower body dressing; extensive assistance with managing medications, phone use, personal hygiene, upper body dressing, walking, locomotion, toileting, and bed mobility; and limited assistance with eating. She has bowel and bladder incontinence.  

Appeal statements indicate the patient has decreasing mental and physical health.  She requires overnight assistance with toileting. Logs show overnight toileting every one to two hours. Due to progression of dementia, she wanders in her apartment. She has an unsteady gait and recent falls. She requires assistance with all activities of daily living (ADLs).

The proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.

This patient has multiple chronic conditions. This is an appeal for denial of increase personal care worker (PCW) to seven days per week, 24 hours per day, continuous care by more than one person, a total of 168 hours per week. The health plan approved an increase from 49 to 63 hours per week. Uniform Assessment System evaluation completed earlier this year shows the patient requires assistance with all activities of daily living (ADLs). She is incontinent of bowel and bladder. The appeal statements support the patient is dependent with all activities of daily living (ADLs) and requires frequent assistance with toileting, and ambulation. She has frequent falls due to attempting to ambulate without assistance. Nighttime logs show the patient requires toileting every one to two hours per night. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care services (PCS) of 63 hours per week is inadequate to meet the patient's needs for assistance with activities of daily living (ADLs). The requested personal care worker services for a total of 168 hours per week, split shift, is medically necessary.