Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, sacral pressure ulcer, hypertension, lung cancer, and osteoarthritis. 
Treatment: Increase Personal Care Worker (PCW) to 7 Days per Week 24 Hours per Day Continuous Care by more than One Person, for a Total of 168 Hours per Week. 

The insurer denied: Increase Personal Care Worker (PCW) to 7 Days per Week 24 Hours per Day Continuous Care by more than One Person, for a Total of 168 Hours per Week. 
The denial is overturned. 

This patient is an elderly female with medical conditions that include dementia, sacral pressure ulcer, hypertension, lung cancer, and osteoarthritis. The denial of an increase in personal care worker (PCW) to seven days per week, 24 hours per day, continuous care by more than one person, for a total of 168 hours per week is being appealed. The health plan approved personal care worker (PCW) service seven days per week, 24 hours per day, live-in, for a total of 91 hour per week. Uniform Assessment System (UAS) evaluation performed five months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances and medications, phone use, bathing, lower body dressing; extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toileting, and eating; and limited assistance with bed mobility. The patient has bowel and bladder incontinence. Uniform Assessment System (UAS) evaluation performed four months ago shows a decline with bathing, personal hygiene, dressing, toilet use, and bed mobility to require total dependence. A letter from the Provider notes the patient has severe limitations in functional and cognitive abilities. She is dependent on others for activities of daily living (ADLs). She has nocturia and incontinence and needs diaper change as well as change in body position every two hours. A letter from another Provider notes the patient needs continuous care. 

The proposed treatment 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. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual who needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. Denial of an increase in personal care worker (PCW) to seven days per week, 24 hours per day, continuous care by more than one person, for a total of 168 hours per week is being appealed. The health plan approved personal care worker (PCW) service seven days per week, 24 hours per day, live-in, for a total of 91 hour per week. Uniform Assessment System (UAS) evaluation completed in four months ago shows a decline from the evaluation performed five months ago to require maximal assistance to total dependence with all activities of daily living (ADLs). She is incontinent of bowel and bladder. The appeal statements support the patient is dependent with all activities of daily living (ADLs) and requires frequent assistance with toileting, transfers, and turning/repositioning. This information provided shows the patient's physical functioning is declining and she has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed increase of personal care worker to seven days per week, 24 hours per day, continuous care by more than one person, for a total of 168 hours per week is medically necessary.