Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glioblastoma; Seizures.

Treatment: Personal Care Worker (PCW) services 12 hours per day, 7 days per week (84 hours per week).

The insurer denied coverage for Personal Care Worker (PCW) services 12 hours per day, 7 days per week (84 hours per week).

The denial is overturned. 

This is a male with a medical history of diffuse grade II midline glioma, seizures, cerebral edema and hydrocephalus status post ventriculoperitoneal (VP) shunt placement. The patient is receiving chemotherapy and radioactive treatments and his health has reportedly rapidly declined over the past year. His treating physicians note that the patient has left-sided weakness, significant mobility and cognitive issues and requires at least 12 hours of care daily. He is dependent in all activities of daily living (ADLs). The Uniform Assessment System (UAS)-New York noted the patient was receiving 35 hours/week of community home healthcare services. He lives with his mother and her partner. The mother had been taking care of the patient, but now has to go back to work. Assistance is required for ADLs; the nursing facility level of care (NFLOC) score is noted to have increased from 20 to 26.

The insurer has denied coverage for Personal Care Worker (PCW) services 12 hours per day, 7 days per week (84 hours per week) as not medically necessary. They state that using a Tasking Tool they can approve 42 hours/week. The patient's personal care needs during a calendar day are sufficiently infrequent and can be safely and adequately met through coordination of care with appropriate medical professionals, providing him with additional specialized equipment when indicated, and continuously monitoring his needs in the community. Additional PCW hours can be requested for scheduled medical appointments. Hours are not extended for safety concerns only. 

The patient is wheelchair-bound and needs assistance with all ADLs. He has deteriorated over the last few months. He is unable to function even with durable medical equipment (DME). 

As per New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 7/6/16 

(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The patient has a glioblastoma still being treated. He has had seizures and has a VP shunt. He had been receiving 42 hours/week of services and a request for 84 hours has been denied. The evaluation by the plan indicates that additional hours are for safety only and would not be coverable. 

The overall impression from UAS reports is that there has not been a substantial change in the patient's level of function. Physician visits indicate that the patient had left-sided weakness affecting ambulation. The patient is now dependent in all ADLs, which is a change. He also had a fall. He no longer has informal help.

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

The patient has functional decline and needs more services than those offered by the plan. As noted above, the documentation supports the need for more services than those specified by the plan.  

Based on the above, the medical necessity for Personal Care Worker (PCW) services 12 hours per day, 7 days per week (84 hours per week) is substantiated. The insurer's denial is overturned.