Appeal type: Medical necessity
Decision: Overturned

Central Nervous System. 
Home Health Care

Diagnosis: cerebrovascular accident (CVA). 
Treatment: Personal Care Worker (PCW) Services. 

The insurer denied an Increase of Personal Care Worker (PCW) Services to 7 Days per Week, 24 Hours per Day, Live-In. The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, coronary artery disease, congestive heart failure, recurrent transient ischemic attack (TIA) / cerebrovascular accident (CVA), long term use of anticoagulant, aphasia, gastroesophageal reflux disease (GERD), unstable gait, osteoarthritis (OA), tremor, urinary incontinence, bowel incontinence, depression, and dementia who had been assigned PCW (personal care worker) services 5 hours/day, 7 days/week, to total 35 hours/week. The patient had a change in neurologic status, pneumonia and urinary tract infection (UTI) with sepsis and was managed at home with her physician daughter with intravenous (IV) treatments avoiding hospitalization at the time with NYC hospitals overwhelmed with COVID-19 patients. The patient saw her cardiologist and it was noted that she needed maximal assistance at home with activities of daily living (ADL). The patient had a fall, dysphagia and weakness. The patient was evaluated by her neurologist with the diagnosis of a new CVA. The patient initially had aphasia, and her dysphagia did improve over the time frame the neurologist closely evaluated her. Eliquis was increase to 5 milligrams (mg) twice daily. There was a request to increase PCW services to 24 hours a day, live-in, 7 days per week and the patient underwent a telephonic assessment tool. The patient was assessed at total assistance for tasks of meal preparation, ordinary housework, managing finances, and shopping while assessed at maximal assistance with tasks of phone use, stairs, transportation, equipment management, bathing, personal hygiene, dressing upper and lower body, transfer toilet, toilet use, and bed mobility. In addition, the patient was assessed that extensive assistance with tasks of managing medication, walking, locomotion, and eating. 

The Increase of Personal Care Worker (PCW) Services to 7 Days per Week, 24 Hours per Day, Live-In is medically necessary for this patient. 

The patient has documented progressive medical diagnoses with worsening functional status following UTI and pneumonia. The patient subsequently had a new neurovascular event with resultant dysphasia and worsening gross motor and fine motor skills. The patient's assessment done assesses that the patient needs some type of assistance with all ADLs and Instrumental activities of daily living (IADL). The patient's needs require 24 hours of care and therefore the task-based assessment should not have been utilized. The patient has unscheduled and unpredictable care needs over a continuum of time. The patient has unscheduled and unpredictable toileting and incontinent care needs and patient does need assistance with safe completion of these tasks. PCW services are not solely for safety and supervision but to assist the patient with safe completion of her ADLs and ADLs. The patient does not have informal helper to assist her outside of the time period that she has PCW services. 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.