Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, syncope, chronic kidney disease, degenerative joint disease, and valvular heart disease
Treatment: Personal Care Worker (PCW) Services - Seven Hours per Day, Seven Days per Week
The insurer denied the personal care worker (PCW) services - seven hours per day, seven days per week.
The denial is upheld. 

This female patient has conditions including hypertension, syncope, chronic kidney disease, degenerative joint disease, and valvular heart disease.  The patient's daughter is appealing denial of personal care worker, seven hours per day, seven days per week.  She has been approved for increase from five to six hours per day, seven days per week.  

Uniform Assessment System evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, and bathing; extensive assistance with managing finances and medications, phone use, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating.  She has bladder incontinence.  She has durable medical equipment (DME) including grab bars, shower chair, walker, and cane.  A bedside commode and rollator were recommended.  The patient has refused physical therapy (PT).  There is a statement that the patient has dizziness and constantly falls.  She has been depressed since the death of her husband.  She walks with a walker and can't get up without external help.  A letter dated from the provider notes the patient needs reminders with medications, cognitive function is decreased and she requires extensive assistance with activities of daily living (ADLs).  Physical therapy (PT) note indicates the patient had a recent fall and demonstrates decreased ability with activities of daily living (ADLs) and ambulation.  A letter from another provider notes the patient has severe dizziness and frequent falls.  The letter states she needs supervision.

No, the proposed personal care worker, seven hours per day, seven days per week, is not medically necessary.

Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs), health maintenance activities, and routine support services.  

This patient has multiple chronic conditions.  She has impaired mobility and history of falls.  The patient's daughter is appealing denial of personal care worker (PCW), seven hours per day, seven days per week.  She has been approved for increase from five to six hours per day, seven days per week.  

Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs), except bed mobility and eating.  She requires limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting.  She has declined physical therapy.  She has durable medical equipment including grab bars, shower chair, walker, and cane; a bedside commode and rollator were recommended.  Appeal letters note the patient has frequent falls and needs assistance with activities of daily living (ADLs) and supervision.  Personal care worker is not indicated for supervision.  The approved personal care worker, six hours per day, seven days per week is sufficient to meet the patient's needs for assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs) as noted above.  The proposed increase in personal care worker to seven hours per day, seven days per week is not medically necessary.