Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip contusion, dementia, diabetes, and osteoarthritis
Treatment: Increase in Personal Care Worker (PCW) service from 7 days per week, 5 hours per day; 35 hours per week to 7 days per week, 24 hours per day, live in; 91 hour per week.
The insurer denied the increase in Personal Care Worker (PCW) service from 7 days per week, 5 hours per day; 35 hours per week to 7 days per week, 24 hours per day, live in; 91 hour per week.
The denial is overturned.

The patient is an elderly female. Her conditions include hip contusion, dementia, diabetes, and osteoarthritis. This is an appeal for denial of increase personal care worker (PCW) from 35 hours per week, to 7 days per week 24 hours per day (live-in), for a total of 91 hours per week. The health plan approved PCW (personal care worker) service 7 days per week, 5 hours per day, for a total 35 hours per week. The request was denied coverage by the health plan based on clinical notes from the nursing home.

Physical and Occupational services report that the patient is able to ambulate 30 feet with help and with use of an assistive device rolling walker. She is able to transfer with help and use a toilet with moderate help. The patient is able to feed herself with supervision help. The meals are prepared in advance and set up. The records include a handwritten statement that the patient has an unstable gait and urinary incontinence. No unmet nighttime needs were identified. The records include a letter from the patient's provider, which notes that the patient was admitted to a nursing home for rehabilitation. Her cognitive and physical functioning declined, and she now requires total assistance. She needs maximum assistance with transfers and is ADL (activities 
of daily living) dependent.

The requested Increase Personal Care Worker (PCW) From 35 Hours Per Week, To 7 Days Per Week 24 Hours Per Day; (live-in); For a Total of 91 Hours Per Week is 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. The patient with multiple chronic conditions. Denial of increase personal care worker (PCW) from 35 hours per week, to 7 days per week 24 hours per day (live-in), for a total of 91 hours per week, is being appealed. The health plan approved PCW (personal care 
worker) service 7 days per week, 5 hours per day, for a total 35 hours per week.

The patient is currently in a nursing home for rehab. The information provided by the health plan indicates the patient's current level of functioning is ambulate 30 feet with help and with use of an assistive device rolling walker, transfer with help and use a toilet with moderate help and feed herself with supervision help. The meals are prepared in advance and set up. A statement from the patient's provider notes that the patient's condition has declined since being in the nursing home to now requiring total assistance. She has urinary incontinence. The information provided supports that this patient needs total assistance. The approved PCW (personal care worker) 35 hours per week is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living). The requested increase to 91 hours per week, live-in, is medically necessary and appropriate.