Appeal type: Medical necessity
Decision: Overturned

Diagnosis: coronary artery disease (CAD), hypertension (HTN), chronic renal disease on dialysis
Treatment: Personal Care Worker (PCW) 12 hours per day, 7 days a week
The insurer denied coverage for Personal Care Worker (PCW) 12 hours per day, 7 days a week
The denial is overturned
 
This is an elderly patient with a history of coronary artery disease (CAD), hypertension (HTN), chronic renal disease on dialysis, worsening short term memory loss and irritability, and multiple falls. It is noted the patient's condition deteriorated over the last few months per her primary physician. The patient had recurrent COVID (coronavirus disease) and progressive dementia. The patient cannot walk with a walker without help. During an assessment the patient reported multiple falls, as well needing help with everything. It is noted the patient reported being scared after her help leaves, as she can't do anything on her own, so she stays in bed.

The patient is currently getting Personal Care Worker eight hours a day, seven days a week. The request is for 12 hours per day, seven days a week, which is under review.

Personal Care Worker (PCW) 12 hours per day, seven days a week is medically necessary for this patient.

The patient is unable to do her activities of daily living (ADLs), is having multiple falls, and her clinical situation is deteriorating after two recurrent COVID infections. Further, the patient has worsening dementia, so she needs more help. The requested hours are appropriate.

"This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems." (Hirdes, J. P. et al. 2022).

Per Landers, S., et al., (2016), "Medicare skilled home health" care or "home health care" refers to services offered by Medicare-certified home health agencies under the Medicare home health benefit. By contrast, "home-based care" refers to a wide array of different types of care provided in the home by a wide range of parties. The continuum of different types of home-based care delivered in the home varies in terms of different dimensions, including acuity, type of care provided, and degree of physician involvement. Home-based care includes both formal and informal personal care services, Medicare skilled home health, physician house calls, and even "hospital-at-home" services." 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Worker (PCW) 12 hours per day, 7 days a week is substantiated.