Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid arthritis, interstitial lung disease, and
failure to thrive.
Treatment: Increase Personal Care Worker (PCW) Service to 7 Days per Week, 24 Hours Live-in, Pre-service.
The insurer denied the Increase Personal Care Worker (PCW) Service to 7 Days per Week, 24 Hours Live-in, Pre-service.
The denial is overturned.

This female has several conditions including rheumatoid arthritis, interstitial lung disease, and failure to thrive.  She is oxygen dependent.  Clinical note notes the patient was admitted with failure to thrive.  She lives alone in a two bedroom apartment of a multi-family home.  Her daughter lives in the basement.  She is appealing the denial of 24 hours per day live in, 7 days per week personal care worker (PCW) services.  The patient has been approved for 56 hours per week.  

Assessment performed shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, and managing finances; maximal assistance with managing medications, shopping, bathing, lower body dressing, and toilet use; extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion and bed mobility; and limited assistance with eating.  She is frequently incontinent.  She ambulates with a walker with assistance.  Personal care logs show frequent diaper changes and position changes.  Appeal letter states the patient's health has declined over several months.  It states the patient requires total assistance with activities of daily living (ADLs).  The appeal letter from NY State notes the patient's condition has deteriorated in recent months: developed incontinence of bowel and bladder; pressure ulcer on sacrum; and failure to thrive.  It notes the patient requires repositioning every two hours to treat her current ulcer.  It recommends 24 hour live in, 7 days per week.

Yes, the proposed treatment is medically necessary.
Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner and the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard 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.  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.  

This patient has multiple chronic conditions including limited mobility due to hypoxia and rheumatoid arthritis; and failure to thrive.  She was hospitalized due to failure to thrive.  Assessment performed shows that the patient requires maximal assistance with all activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  She has a pressure ulcer and requires turning/repositioning every two hours and frequent diaper changes due to incontinence.  There is evidence of frequent diaper changes and repositioning throughout the day.  Information provided shows the patient's condition is deteriorating.  This patient requires one-on-one care throughout the day and night.  The approved 56 personal care worker (PCW) service hours per week are insufficient to meet this patient's needs with assistance with ADLs and personal care as noted above.  The proposed increase to 24 hours per day live-in, 7 days per week is medically necessary.