Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, rheumatoid arthritis, urinary incontinence, peripheral vascular disease, hypertension, depression, dizziness. 
Treatment: Increase Personal Care Worker (PCW) Services to Seven Days per Week 24 Hours per Day Live-in. 

The insurer denied the Increase Personal Care Worker (PCW) Services to Seven Days per Week 24 Hours per Day Live-in. 
The denial is overturned. 

This female has medical conditions including chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, urinary incontinence, peripheral vascular disease (PVD), hypertension, depression, dizziness and unsteadiness on feet.  She is appealing denial of personal care worker (PCW) 24 hours per day, live-in.  She was partially approved for personal care worker (PCW) 56 hours per week. 

The patient currently lives at a facility.  Records show the patient is able to ambulate 25 to 30 feet with a rolling walker and assistance.  She is able to transfer with assistance; perform toileting with maximal assistance; and eat with set-up. She has no informal support.  Uniform Assessment System (UAS) evaluation performed shows the patient's functional status: total assistance with housework; maximal assistance with meal preparation; extensive assistance with bathing, lower body dressing, and managing medications; limited assistance with personal hygiene, upper body dressing, toilet use, and walking/locomotion; and supervision with toilet transfer and eating.  She is incontinent of bowel and bladder.  Appeal letter from the provider states the patient needs total assistance with all activities of daily living (ADLs), including transfer from bed to wheelchair.  Appeal statement from New York notes the patient needs assistance with activities of daily living as already accounted for in the Uniform Assessment System (UAS) evaluation.  The appeal notes the patient needs assistance with turning/repositioning while in bed.  The appeal notes current care would require that the patient remain in a soiled diaper for 12+ hours per day. 

Yes, the proposed treatment is medically necessary. 

The proposed treatment is consistent with generally accepted standards of medical practice. 

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding. 

This patient has multiple chronic conditions.  Uniform Assessment System (UAS) evaluation completed showed the patient needed assistance with all activities of daily living (ADLs) with the exception of toilet transfer and eating.  She currently lives at a facility and has no informal support.  Clinical records from the facility, show the patient is able to transfer and ambulate with assistance.  Appeal letter from the provider states the patient needs total assistance with all activities of daily living, including transfer from bed to wheelchair.  She is incontinent and requires assistance with diaper changes.  Appeal letter from New York dated states this patient needs assistance with activities of daily living both day and night.  The appeal states assistance needed includes turning/repositioning while in bed, transfers, and toileting.  Based on the current hours, the patient can remain in a soiled diaper for over 12 hours.  

This patient has continuous needs that cannot be met with the approved personal care worker (PCW) 56 hours per week.  The proposed increase in personal care services (PCS) to 24 hours per day, live-in, is medically necessary to meet this patient's need for assistance with activities of daily living (ADLs) and personal care.