Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, epilepsy, and osteoarthritis
Treatment: Personal Care Worker (PCW) 2 shifts of 12 hours per day, 7 days per week, for a total of 168 hours per week
The insurer denied the Personal Care Worker (PCW) 2 shifts of 12 hours per day, 7 days per week, for a total of 168 hours per week.
The denial is upheld.

The patient is a female. She has medical conditions including dementia, epilepsy, and osteoarthritis. The patient lives alone. The appeal is regarding denial to Personal Care Worker (PCW) 2 shifts of 12 hours per day, 7 days per week, for a total of 168 hours per week. She has been approved for PCW 13 hours per day, 7 days per week, for a total of 91 hours per week.

The patient's UAS (Uniform Assessment System) evaluation completed shows the patient has severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, phone use, shopping, bathing, locomotion, and lower body dressing; maximal assistance with managing medications, personal hygiene, upper body dressing, walking, toileting, and bed mobility; and extensive assistance with eating. She requires weight bearing assistance while using a walker. She has bowel and bladder incontinence. Compared to UAS evaluation completed previously, significant findings show a decline in locomotion.

An appeal statement notes the patient needs 2 shifts of 12 hours per day, 7 days per week due to deterioration in her health and for assistance with ADLs (activities of daily living). She has limited support of children.

No, the increase in personal care worker to 168 hours per week is not 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 service is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that 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. The appeal is regarding denial of PCW 2 shifts of 12 hours per day, 7 days per week, for a total of 168 hours per week. She has been approved for PCW of 13 hours per day, 7 days per week, for a total of 91 hours per week.

This patient has multiple chronic conditions including dementia. The patient lives alone. UAS evaluation shows the patient requires assistance with all ADLs/IADLs (instrumental activities of daily living). Other than extensive assistance with eating, she requires maximal assistance to total dependence. The patient is incontinent of bowel and bladder. The appeal statement notes there has been a deterioration in the patient's health requiring increased assistance to 2 shifts of 12 hours per day, 7 days per week. There is no documentation that the patient requires continuous needs such as frequent turning/repositioning. PCW is not indicated for supervision. Therefore, the approved PCW 13 hours per day is appropriate to meet the patient's needs for assistance with ADLs/IADLs. The proposed increase to PCW 2 shifts of 12 hours per day, 7 days per week is not medically necessary.