Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, heart disease
Treatment: Increase Personal Care Worker (PCW) to 7 Days per Week, 24 Hours a Day, Continuous Care by more than One Person for a total of 168 Hours per Week
The insurer denied Increase Personal Care Worker (PCW) to 7 Days per Week, 24 Hours a Day, Continuous Care by more than One Person for a total of 168 Hours per Week.
The denial is overturned.

This patient is an adult female with medical conditions that include Alzheimer's dementia, varicose veins, hyperlipidemia, heart disease, and peptic ulcer. She is homebound. The denial of an increase in personal care worker (PCW) service to seven days per week, 24 hours a day, continuous care by more than one person, for a total of 168 hours per week is being appealed. 
The health plan approved seven days per week, 24 hours per day, live in, for a total of 91 hours per week. Uniform Assessment System (UAS) evaluation completed 7 months ago shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, phone use, and shopping; maximal assistance with managing medication, bathing, and lower body dressing; extensive assistance with personal hygiene, upper body dressing, and toileting; and limited assistance with walking, locomotion, bed mobility, and eating. The patient has bowel and bladder incontinence. There has been a significant decline in functioning compared to Uniform Assessment System evaluation completed from last year. A letter from the patient's child notes the patient needs help going to the bathroom two to three times per night. A letter from the Provider notes the patient's mental and functional status are deteriorating. The patient is homebound. She has frequent episodes of anxiety, agitation, and confusion. She wanders at night. She is at high risk for falls.

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 who 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. The denial of an increase in personal care worker (PCW) services to seven days per week, 24 hours a day, continuous care by more than one person, for a total of 168 hours per week is being appealed. The health plan approved seven days per week, 24 hours per day, live in, for a total of 91 hours per week. Uniform Assessment System (UAS) evaluation completed 7 months ago showed the patient requires assistance with all activities of daily living (ADLs). She is incontinent of bowel and bladder. Compared to Uniform Assessment System evaluation completed last year, there has been a decline the patient's functional status. Appeal statements indicate there has been a deterioration in the patient's mental and functional status. The patient is a fall risk. She awakens during the nighttime and needs assistance with toileting every two to three hours. These appeal statements support that the patient has continuous needs with toileting that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed increase in personal care worker (PCW) services to seven days per week, 24 hours a day, continuous care by more than one person, for a total of 168 hours per week is medically necessary.