Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CAD (coronary artery disease), chronic kidney disease, depressive disorder, anemia and dizziness
Treatment: Increase Personal Care Worker (PCW) Service to Seven Days per Week 12 Hours per Day
The insurer denied the Increase Personal Care Worker (PCW) Service to Seven Days per Week 12 Hours per Day
The denial is upheld

The patient is a male. His diagnoses including CAD (coronary artery disease), chronic kidney disease, depressive disorder, anemia and dizziness.  His wife passed away earlier in the year.  He lives alone.  Denial of increase Personal Care Worker (PCW) Service to seven days per week 12 hours per day is being appealed.  The Plan approved 4 Days Per Week, 5 hours per day (Tuesday, Thursday, Saturday, Sunday) and 3 Days Per Week 4 Hours Per Day (Monday, Wednesday Friday).

UAS (Uniform Assessment System) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances, shopping, and lower body dressing; extensive assistance with managing medication, phone use, stairs, bathing, personal hygiene, and upper body dressing; and limited assistance with walking, locomotion, toileting, bed mobility and eating.  The patient is incontinent of bowel and bladder.  Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functioning with transportation and personal hygiene.  He uses a cane as an assistive device.

An appeal statement dated requests additional hours to meets needs with ADLs (activities of daily living) and personal care as already accounted for in the UAS (Uniform Assessment System) evaluation.  The request notes the patient needs assistance with scheduled and unscheduled tasks. It notes that the patient's condition continued to decline over a five month period of time.

An appeal letter from the patient's provider notes the patient is homebound and has several falls at night when unsupervised. The letter notes the patient has poor safety awareness.  The letter requests additional hours for assistance with ADLs (activities of daily living) and fall prevention.

An appeal letter from the patient's daughter notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation completed.  The letter notes that the daughter is no longer able to provide informal support.

No, the requested increase in personal care worker to 12 hours/day, 7 days/week, is not medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase Personal Care Worker (PCW) Service to seven days per week 12 hours per day is being appealed. The Plan approved 4 Days Per Week, 5 hours per day (Tuesday, Thursday, Saturday, Sunday) and 3 Days Per Week 4 Hours Per Day (Monday, Wednesday Friday).

This patient has multiple chronic medical conditions. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living) to include limited assistance with walking, locomotion, toileting, bed mobility and eating. He is incontinent of bowel and bladder. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functioning with transportation and personal hygiene. Appeal statements note there has been a deterioration in the patient's condition. They note the patient has a history of falls and additional hours are needed for supervision for safety. PCW (Personal Care Worker) is not indicated for supervision or when no tasks are being performed. The currently approved PCW (Personal Care Worker) hours per week are appropriate and medically necessary to meets the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in PCW (Personal Care Worker) to seven days per week 12 hours per day is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.