Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hemiplegia, dementia, coronary artery disease
(CAD), heart failure and depression. 
Treatment: Increase Personal Care Worker (PCW) Services From Seven Days per Week, Seven Hours per Day to Seven Days per Week, 12 Hours per Day. 

The insurer denied the Increase Personal Care Worker (PCW) Services from seven days per week, seven hours per day to seven days per week, 12 hours per day. 
The denial is upheld. 

This female patient has conditions including cerebral vascular accident times two with right-sided hemiplegia, dementia, coronary artery disease (CAD), heart failure and depression.  She lives alone.  She is appealing denial of increase in Personal Care Worker (PCW) Services from seven days per week, seven hours per day to seven days per week, 12 hours per day. 

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances, phone use, shopping, bathing, lower body dressing, locomotion, and toilet use; extensive assistance with managing medications, personal hygiene, upper body dressing, toilet  transfer, and bed mobility; and limited assistance with eating.  She is non-ambulatory.  She uses a wheelchair and scooter.  She has bowel and bladder incontinence.  Durable medical equipment (DME) includes wheelchair, shower chair, grab bar, commode, walker, and incontinent supplies. 

The patient was recently prescribed medication for memory, awareness and activities of daily living (ADLs).  She is scheduled to see a psychiatrist/neurologist for further evaluation.  She is recommended for skilled nursing services and physical therapy (PT) by a home health agency. 

An appeal statement from the provider states the patient is bed/home/wheelchair bound.  It states the patient has amnesia and cannot safely manage medications.  It notes need for assistance with activities of daily living (ADLs).  The patient was hospitalized due to syncope and fall secondary to bradycardia, which is undergoing cardiology evaluation.  It states the patient is not safe to be left alone. 

No, the proposed Increase in Personal Care Worker (PCW) Services to Seven Days per Week, 12 Hours per Day is not medically necessary. 
Personal Care 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 several chronic conditions including dementia and is status post stroke with right-sided hemiplegia.  She is non-ambulatory.  She was recently hospitalized with syncope.  She lives alone.  She is appealing the denial of an increase in Personal Care Worker (PCW) Services from seven days per week, seven hours per day to seven days per week, 12 hours per day. 

Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs).  She has bowel and bladder incontinence.  The patient is undergoing work up for memory and bradycardia.  Appeal statement notes the patient is not safe to be left alone.  Personal care worker (PCW) is not indicated for supervision or when no tasks are being performed.  The additional assistance this patient requires (e.g. medication reconciliation, physical therapy evaluation, durable medical equipment recommendations and health education) is outside the scope of a personal care worker (PCW) and would fall within the category of skilled needs.  The approved personal care worker (PCW) seven days per week, seven hours per day is sufficient to meet the patient's needs for assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs).  The proposed increase in personal care worker (PCW) to seven days per week, 12 hours per day is not medically necessary. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.