Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation, hypertension, coronary artery disease, hyperlipidemia, peripheral vascular disease, pedal edema.
Treatment: Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day, live-in.
The insurer denied coverage for Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day, live-in.
The denial is overturned.

This elderly female has significant functional impairment associated with several medical conditions. She needs assistance for all daily activities. She lives alone and primarily relies on personal care worker (PCW) services for help with activities of daily living (ADL) and instrumental (I) ADLs. She receives PCW services 11 hours per day, 7 days per week. The patient also receives informal care from her children. It was noted in the UAS (Uniform Assessment System) that the children live 1 12 hours away and take turns providing care after PCW hours (the length of time is not clear, but UAS reported 12 hours of informal care over previous 3 days). Patient requested increase of PCW services to 24 hours per day, live in, which was denied. 

The functional status report indicates patient is totally dependent for housework; she needs maximal assistance for meal preparation, shopping, transportation, stairs, equipment management; extensive assistance for phone use, and managing finances and medications. The patient needs maximal assistance for most ADLs, except bed mobility (extensive assistance) and eating (limited assistance). It was noted that the patient was not transferred to the toilet the entire period.  Functional decline in older people is usually the result of cumulative and interactive effects of multiple medical conditions resulting in physical and/or cognitive impairment. Other factors include economic and social circumstances, (e.g., caregiver support). The patient has several medical conditions that contribute to her impaired ability to perform daily activities. 

Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present during the day and night to provide assistance with all routine ADLs and IADLs, and with ADLs that occur at various unscheduled and recurring times throughout the day and night (including toileting/incontinence care, transfers, walking, bed mobility). Without a caregiver to provide assistance, the patient is at increased risk for adverse medical and safety events including incontinence associated skin damage; pressure ulcers; UTI (Urinary Tract Infection); inadequate pain control; falls/injury.  

MLTC (Managed Long-Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. When the patient needs incontinence care and repositioning in bed; this is not stand-alone safety supervision. This is assistance the patient needs for proper and safe completion of ADLs. These care needs must be considered in the determination of the patient's personal care service hours.

It is medically necessary for the patient to have caregiver assistance for ADLs at various times of the day and night to prevent adverse health and safety events as noted in this review.  With live-in services, the patient will benefit from additional ADL assistance during the evening/night hours that is not available to her with her current services (PCW 11 hours per day). 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day, live-in is overturned. Medical Necessity is substantiated.