Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Osteoporosis

Treatment: increase in personal care worker (PCW) services to 7 days per week, 12 hours per day; 84 hours per week

The insurer denied coverage for increase in personal care worker (PCW) services to 7 days per week, 12 hours per day; 84 hours per week

The denial is modified

This is an elderly patient with chronic medical problems including hypertension, hypothyroid and osteoporosis. The patient lives alone in a private residence. The insurer approved personal care worker (PCW) 7 hours/day- 7 days/week- for a total of 49 hours/week. The insurer denied the request for PCW 7 days per week; 12 hours per day for a total of 84 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as minimally impaired. The patient is reportedly total dependent for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for lower body dressing. Extensive assistance is reportedly needed for bathing, personal hygiene, upper body dressing, and toilet transfer/use. Limited assistance is reportedly needed for eating, bed mobility, locomotion and ambulation. The patient reports having fallen on 1 occasion over the prior 30 days. The patient reports being frequently incontinent of bladder and occasionally incontinent of bowel. The patient's ability to perform activities of daily living (ADL) tasks and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. However, the patient's cognitive and functional ability are much the same when compared to the previous UAS reports. There has been a modest (functional) decline when compared to another previous UAS report.

Based on the submitted documents reviewed, the patient does not have functional needs at a level or unpredictable as to require the requested PCW 7 days per week; 12 hours per day; 84 hours per week.  The letter from the patient's treating physician describing the patient's clinical condition was reviewed, noting "because of dementia the patient is left unattended rest of the day and I would like to request more hours" was reviewed.  

The reviewer would agree the patient may benefit from additional monitoring for safety; particularly due to their reported cognitive deficits, weakness and falls risk.  However, PAS hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance.  The reviewer would also agree the patient's functional deficits are substantial and increasing the patient's PCW hours is clinically appropriate.  Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCW to 9 hours/day, 7 days/week; totaling 63 hours/week.  The patient also has the option of restructuring and flexibly using the 63 PCW hours weekly to better maintain and meet the patient's functional needs.

From a physical medicine and rehabilitation perspective, increasing PCW services to 7 days per week; 12 hours per day; 84 hours per week is not medically necessary.  However, increasing PCW to 7 days per week; 9 hours per day; 63 hours per week is medically necessary.    

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in personal care worker (PCW) services to 7 days per week, 12 hours per day; 84 hours per week is not substantiated. However, increasing PCW to 7 days per week; 9 hours per day; 63 hours per week is medically necessary.