Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility.
Treatment: home health care.
The insurer denied Personal Care Worker (PCW) Services: 11 Hours per Day, 7 Days per Week. 
The health plan's determination is overturned. 

The patient is a female with a past medical history of dementia, seizures, diabetes mellitus type 2, hypertension, asthma, glaucoma, chronic constipation, gastroesophageal reflux disease (GERD), hyperlipidemia, asthma, hypothyroidism, and urinary incontinence who had shared PCW (personal care worker) services with her husband to total 77 hours/week. The patient's husband died recently and the insurer reduced PCW services to 7 hours/day, 7 days/week, to total 49 hours/week. There was a request to increase PCW services and the patient underwent an assessment assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, stairs, shopping, and transportation. With tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while independent with tasks of bed mobility and eating. 

Personal Care Worker (PCW) Services: 11 Hours per Day, 7 Days per Week are medically necessary for this patient.
There is documentation from the patient's primary care physician (or provider) (PCP) and son of cognitive and functional decline. The patient's husband had served as some informal support prior to his death and as a mutual case they had been assigned 11 hours/day, 7 days/week. The patient requires assistance with all tasks except for bed mobility and eating and has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document to meet these unpredictable and unscheduled care needs. The requested increase in PCW services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient has a history of seizure disorder and requires assistance with medication management to prevent further seizures. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as noted by the insurer. The patient requires assistance with transfer toilet and toilet use. The plan incorrectly assumed the patient had informal support outside of all of the current PCW service hours. Physical Therapy report was not available for review but the insurer's final adverse determination noted this report was required in making their decision. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCW services 11 hours/day, 7 days/week, to total 77 hours/week 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 her own home.