Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, right eye blindness, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD). 

Treatment: PCW (personal care worker) services 7 days per week, 9 hours per day, for a total of 63 hours per week. 

The insurer denied coverage for PCW services 7 days per week, 9 hours per day, for a total of 63 hours per week. 

The denial is overturned. 

This female has extensive medical history associated with functional impairment and needs assistance with all daily activities. She lives with her two sons. The UAS (Uniform Assessment System) indicates they provide some informal care but there no details as to when they are home and available to assist, and for which ADLs (Activities of Daily Living) and/or IADLs (Instrumental Activities of Daily Living) they provide assistance. The patient relies primarily on personal care worker (PCW) services. She was receiving PCW 6 hours per day, 6 days per week, 36 hours per week. The patient's physician requested increase of PCW services to 7 days per week, 9 hours per day, 63 hours per week, which was denied; but the insurer increased PCW services to 7 days per week, 6 hours per day, 42 hours per week. An appeal was requested, but the denial for 63 hours per week was upheld, and so the patient is receiving PCW 42 hours per week. An external appeal was requested. 

Considering the information provided for review, it is medically necessary for the patient's health and safety to have caregiver support for all routine ADLs and IADLs, and ADLs that occur at unscheduled and recurring times throughout the day, including toileting and mobility. MLTC (Managed Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. All the patient's care needs throughout the day must be considered in the determination of personal care service hours. Additional PCW hours would not be used for stand-alone safety supervision; assistance is needed for proper and safe completion of daily activities. 

The records indicate the patient's sons provide some informal care, but there is no description of their schedule and availability for assisting the patient. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day (e.g., transfer, walking, toileting). Considering the patient (via designee) is requesting PCW 9 hours per day, 7 days per week, it is reasonable to conclude that there are no informal caregivers available to provide that amount of assistance on a regular basis each day. The patient will benefit from PCW assistance for a longer period of time each day to accommodate more of her personal care needs. 

Recommendation is given to approve Personal Care Worker services 7 days per week, 9 hours per day, 63 hours per week. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for personal care worker (PCW) services 7 days per week, 9 hours per day, for a total of 63 hours per week is overturned. Medical Necessity is substantiated.