Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis. 
Treatment: Personal Care Worker (PCW) services from 5 days per week, 4 hours per day; 20 hours per week to 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person. 

The insurer denied Personal Care Worker (PCW) services from 5 days per week, 4 hours per day; 20 hours per week to 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person. 
The denial is Overturned. 

The patient is a female with past medical history of displaced fracture of left ankle, spinal stenosis, rheumatoid arthritis, atrial fibrillation, heart disease. The health plan partially approved 7 days a week, 8 hours a day; 56 hours of personal care assistance (PCA). 
The patient had been assigned PCA services based on assessment tool performed assessing the patient as modified independent cognition with no memory problems. No hearing difficulties or vision difficulties. The patient was assessed maximal assistance with task of ordinary housework and meal preparation. Supervision with medications and maximal assistance for shopping. The patient was assessed at extensive assistance with task of bathing, limited assistance with personal hygiene, limited assistance with dressing upper body, extensive assistance with dressing lower body, limited assistance with walking and limited assistance with locomotion, transfer toilet and extensive assistance with toilet use and limited assistance with bed mobility and limited assistance with eating. Infrequently bladder and bowel continent. Mini mental state examination score was 28. 

The patient was admitted to rehabilitation facility after a fracture. The patient's treating provider at wrote a medical necessity letter. The provider stated that patient was able to ambulate 75 feet with platform worker with supervision and contact guard assistance and has an unsteady gait with high risk of falls. She also has difficulty navigating stairs, she also requires maximum assistance with toileting and dressing, and requires minimal to moderate assistance for sit/stand transfer and will require assistance at night for transfers and recommends 24 hours of assistance. 
Overnight logs were provided showing that patient with toileting needs 2- 3 times during the night hours.
The subject under review is the increase in Personal Care Worker (PCW) services from 5 days per week, 4 hours per day; 20 hours per week to 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person. 

The health plan's determination is overturned. 

The requested health /treatment of Personal Care Worker (PCW) services from 5 days per week, 4 hours per day; 20 hours per week to 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person is medically necessary for this patient. 
The patient's current level of function based on documentation by the rehabilitation facility, the patient requires assistance with transfers, bed mobility and toileting, she requires hands-on assistance which durable medical equipment (DME) only cannot provide for patient as requires physical assistance. She also has toileting needs overnight based on review of logs noted at rehabilitation, thus requires assistance during overnight hours thus, the requested additional hours are medically necessary.