Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Incontinence, seizure disorder, hypothyroidism, and vascular dementia.
Treatment:  Personal care worker (PCW) services 7 days/week, 12 hours/day, 84 hours/week.

The insurer denied coverage for personal care worker (PCW) services 7 days/week, 12 hours/day, 84 hours/week.  The denial is overturned.

This case involves a female who was denied coverage for an increase in personal care worker services to 7 days/week, 12 hours/day, 84 hours/week. The patient was approved for personal care worker services 7 days/week, 5 hours/day, 35 hours/week based upon an assessment. It was determined that she required assistance with grooming, dressing, bathing, walking, locomotion, transferring, toilet, meal preparation, and feeding and that services could be rendered 7 days/week, 5 hours/day, 35 hours/week. An appeal was submitted indicating that the patient had a history of incontinence, seizure disorder, hypothyroidism, and vascular dementia. She had been hospitalized several times throughout the past year due to the effects of worsening dementia and required continual prompting and cueing for all activities of daily living, including transferring, toileting, bathing, meal preparation, and medication management. Due to her mental deficits, she was at further risk for functional decline. The report went on to state that the patient was unable to manage her activities of daily living independently and her current personal care authorization was no longer appropriate. This review pertains to the denial of coverage for personal care worker services 7 days/week, 12 hours/day, 84 hours/week.

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

Personal care worker services, 7 days/week, 12 hours/day, 84 hours/week is considered medically necessary for this patient.

Current medical literature has noted that typical activities of daily living can create a variety of problems for older individuals who experience age-related loss of musculoskeletal and sensory functioning. These individuals typically find that routine activity becomes more difficult, more time-consuming, and more hazardous. Services like personal assistance are not viewed as an entitlement and often are controlled by organizations such as health care agencies instead of being directed by people obtaining the services. For individuals who have cognitive decline, individualized services are needed to meet the needs of the patient, and in the case of this individual, she required maximal assistance with toileting, extensive assistance with personal hygiene and dressing, along with prompting and cueing with walking and locomotion. She has frequent incontinence of the bladder and relies heavily on assistance. The minimal increase in improved hours from 7 days/week, 4 hours/day, 20 hours/week up to 7 days/week, 5 hours/day, 35 hours/week was minimal and was insufficient in addressing the needs of the patient. Given her loss of cognition and physical impairments, she is at an increased risk for falls and subsequent injury.  Additionally, without available assistance throughout the day, the patient is also at an increased risk for skin breakdown should she have incontinence and a lack of judgment to remove and/or change soiled garments. Based upon the provided information, the prior determination should be overturned given that the personal care worker (PCW) services, 7 days per week, 12 hours per day, 84 hours per week is medically necessary.

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, 7 days per week, 12 hours per day, 84 hours per week is overturned. Medical Necessity is substantiated.