Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, back pain, gait dysfunction, incontinence, and legal blindness due to macular degeneration  

Treatment: Increase Personal Care Worker (PCW) Services From 7 Day(s) Per Week, 7 Hours Per Day To 7 Day(s) Per Week, 24 Hours Per Day, Live in, Pre-service  

The insurer denied the Increase Personal Care Worker (PCW) Services From 7 Day(s) Per Week, 7 Hours Per Day To 7 Day(s) Per Week, 24 Hours Per Day, Live in, Pre-service.  

The denial is overturned.  

The patient is a female. She has conditions including cognitive impairment, back pain, gait dysfunction, incontinence, and legal blindness due to macular degeneration. This is an appeal for denial of PCW (personal care worker) services at 24 hours per day, live in. She was approved for 56 hours per week after provider requested services 24 hours per day. Assessment performed shows minimally impaired cognition and functional status: total dependence with housework; maximal dependence with meal preparation, managing finances, shopping, bathing, and lower body dressing; extensive assistance with managing medications, phone use, personal hygiene, upper body dressing, and toilet use; limited assistance with walking, locomotion, toilet transfer, and eating; and independent with bed mobility.  

The patient is frequently incontinent of bowel and bladder. A letter from the patient's provider states the patient requires assistance with ADLs (activities of daily living). It states the patient has urinary and fecal incontinence, and the aide arrives to find her soiled. It states the patient is a high fall risk. A letter from a second provider states the patient's ability to ambulate is guarded and she is a high fall risk when walking to the restroom in the evening. A letter from a third provider states advanced AMD (aging macular degeneration) impairs ADLs (activities of daily living), especially when alone. It states the patient has an uncontrollable bladder that has led to urinary infections. Records provided show the patient had three recent falls. She was admitted to the hospital after an unwitnessed fall.  

The patient's family reports that the patient gets up two to four times at night and is disoriented. She does not always use a rollator. She attempts to go to the bathroom despite Depends and commode. Some nights, she forgets to eat dinner. 

Yes, the increase in personal care worker (PCW) services from 7 days per week, 7 hours per day to 7 days per week, 24 hours per day, live-in 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, 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 ADLs, including toileting, walking, transfers, turning/positioning, or feeding. Personal care service is necessary when assistance cannot be met from use of from informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. 

This patient has several chronic conditions, including cognitive impairment. She is appealing denial of increase PCW services from 56 hours per week to 24 hours per day, live-in. Assessment performed shows the patient requires assistance with all ADLs and personal care with the exception of bed mobility. Appeal letters from her providers are supportive of live-in services. These letters document conditions including cognitive impairment, bowel/bladder incontinence, gait instability, and legal blindness. The patient is incontinent throughout the entire day. She attempts to walk to the bathroom overnight and has been found in the morning to be soiled. She has fallen three times and was hospitalized after one fall. It was also noted that she forgets to eat at night. The patient has adaptive equipment but forgets to use it. This patient's cognitive and physical functioning are significantly impaired. As per the assessment, she requires significant assistance. The documentation provided shows that she requires assistance during the day and night for mobility, eating and toileting.  This patient's needs cannot be met with 56 PCW hours per week. The requested 24 hours per day, live-in, PCW services are medically necessary.