Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Personal care worker (PCW) services 7 days per week, 24 hours per day; 168 hours per week continuous care by more than one person.

The health plan denied Personal care worker (PCW) services 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 upheld.

The patient is a female with a past medical history significant for dementia, generalized weakness, gait instability, back pain, osteoarthritis, urinary incontinence, insomnia, hypertension, coronary artery disease, osteoporosis, asthma, and a sacral decubitus ulcer stage II.
This review is for the medical necessity of personal care worker service hours, 7 days per week 24 hours a day for a total of 168 hours a week, continuous care by more than 1 person. The patient is currently approved for 10 hours per day 7 days a week.

Services were denied by her health plan stating that the patient is approved for 10 hours a day of services and additional needs can be met by adaptive or special equipment and/or supplies that can be provided safely and cost effectively. Incontinence supplies meet the quality standards for breathability and retention capacity under the New York State Medicaid incontinence supply management program. The plan is not required to include safety monitoring as a separate task on her test-based forms, assess the need for safety monitoring as a separate task or calculate any minutes allotted for safety monitoring as part of the total personal care service hours authorized for personal care services recipients. The patient has additional services for wound care provided by visiting nurses. Sacral wound, home health nurse is providing wound care 2 times a week. Wound is noted as stage II.

At issue is the medical necessity of the requested increase in personal care worker (PCW) services.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service is not medically necessary for this patient.
I recommend upholding the previous decision based upon the following rationale: additional services over 70 hours a week are not medically necessary.
The patient is a female with multiple problems including dementia and generalized debility. She is bedbound.
The patient is currently receiving 70 hours a week of services which are sufficient to meet the patient's needs. Specifically, there are no nocturnal needs that are not met or cannot be provided for with adaptive or special equipment, specifically incontinence supplies. It is noted that the patient is incontinent less than 1 time a day. It is also noted that the patient needs limited assistance with bed mobility. It is also noted that the patient does have a stage II sacral decubitus ulcer. Images were reviewed. The patient is currently receiving treatment through separate services, visiting nurse for wound care.
It is my opinion that the number of services provided are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" without services being provided are not medically necessary. In order for services to be considered medically necessary, the aid must be performing a service such as medically necessary activities of daily living (ADL) or Instrumental activities of daily living (IADL).