Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity, leg edema, foot ulceration, urinary incontinence, osteoarthritis, and abnormalities of gait and mobility. 

Treatment: Increase Personal Care Worker (PCW) Services To 7 Days Per Week 24 Hours Per Day Live-in for 91 Hours Per Week. 

The insurer denied the Increase Personal Care Worker (PCW) Services To 7 Days Per Week 24 Hours Per Day Live-in for 91 Hours Per Week. 
The denial is upheld. 

The patient is a female. Her conditions include morbid obesity, leg edema, foot ulceration, urinary incontinence, osteoarthritis, and abnormalities of gait and mobility. She lives with her husband who is unable to provide physical assistance. Denial of increase personal care worker (PCW) services to 7 days per week 24 hours per day, live-in, for 91 hours per week, is being appealed. The health plan approved PCW (personal care worker) services to 7 days per weeks, 5 hours per day for 35 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows the patient has modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, stairs, shopping, bathing, lower body dressing, toilet use, and bed mobility; extensive assistance with managing finances and upper body dressing; and limited assistance with manning medications, personal hygiene, walking, locomotion, and eating. The patient has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a deterioration in functioning with housework, toilet use, and bed mobility. She has durable medical equipment that includes a walker, shower bench, grab bar, toilet seat, chair lift, wheelchair, bedpan, recliner, and incontinence supplies. 

An appeal statement notes the patient has difficulty performing ADLs (activities of daily living) due to need for assistance to ambulate and transfer for scheduled and unscheduled activities. She is incontinent of bowel and bladder and needs assistance changing diapers. She has no informal support. 

An appeal letter notes the patient is homebound and unable to perform ADLs/IADLs (activities of daily living/instrumental activities of daily living). She needs reminders for medications. Notes she cannot be left alone for extended periods. The patient has mobility limitations due to medical conditions. 

No, the increase in personal care worker services to 91 hours/week, live-in, is not medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase PCW (personal care worker) services to 7 days per week 24 hours per day, live-in, for 91 hours per week, is being appealed. The health plan approved PCW (personal care worker) services to 7 days per weeks, 5 hours per day for 35 hours per week. 

This patient has multiple chronic medication conditions, including mobility limitations. UAS (Uniform Assessment System) evaluation completed, shows the patient requires assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a deterioration in functioning with housework, toilet use, and bed mobility. The patient has bowel and bladder incontinence. Appeal statements show that the patient has mobility limitations and needs assistance with all ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. Statements note the patient needs reminders with medications and cannot be left along. The information provided does not support that the patient has nighttime needs that require a live-in aide. PCW (personal care worker) is not indicated for supervision or when no tasks are being performed. The approved PCW (personal care worker) 35 hours per week is appropriate to meets the patient needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase PCW (personal care worker) services to 7 days per week 24 hours per day, live-in, for 91 hours per week is not medically necessary. 

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