Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive decline
Treatment: Personal care worker (PCW) services, 7 days per week, 24 hours per day, continuous care by more than 1 person, 168 hours per week
The insurer denied PCW services, 7 days per week, 24 hours per day, continuous care by more than 1 person, 168 hours per week.
The determination is overturned.

The patient has a past medical history of Parkinson's disease, cognitive decline, chronic obstructive pulmonary disease (COPD) on chronic oxygen, hyperlipidemia, congestive heart failure (CHF), anxiety, depression, gastroesophageal reflux disease (GERD), hypothyroidism, urinary incontinence, recurrent urinary tract infection (UTI) who had been assigned personal care assistant (PCA) services based on an assessment performed telephonically, assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, shopping, transportation, equipment management, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. With the tasks of phone use, personal hygiene, dressing upper body, bed mobility, and eating the patient was assessed at extensive assistance. Notes stated the patient had moderate cognitive impairment, had improvement in activities of daily living (ADL) status and overall self-sufficiency, and had a pressure ulcer on her buttock.

An office note from the patient's primary care physician (or provider) (PCP) stated the patient had a history of decubitus ulcer and although they had improved, were worsening again. Overnight care logs were provided, noting the patient needed assistance with walking, locomotion, transfer toilet, toilet use, getting a drink, and bed mobility at least every 3 hours overnight. There was a referral to a visiting nurse service because of the patient's decubitus ulcers. There was a request to increase PCA services and the patient underwent an assessment, assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, and transportation while maximum assistance with the tasks of managing medication, phone use, equipment management, bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use. With the tasks of walking, locomotion, and bed mobility, the patient was assessed at extensive assistance while limited assistance with task of eating. Notes from the assessment stated the patient had severe cognitive impairment, lived with her son who was not involved in her care, had a Mini-Mental State Examination (MMSE) of 9 out of 30, and had a daughter that lived 3 houses away who was able to provide medication management on a daily basis.

The insurer sent a final adverse determination notice, stating the patient was approved for PCA services 24 hours/day, live-in, 7 days/week and the request for PCA services 24 hours/day, continuous, 7 days/week was not medically necessary and the patient did not meet criteria. The denial also stated based on a review of the assessment, a letter from the patient's PCP, and night logs provided, the patient's ADL needs and nighttime needs during the day and night, such as grooming, dressing, bathing, transferring, toileting, meal preparation, and feeding, are sufficiently infrequent. The denial stated the patient's needs could be scheduled and adequately met through the combination of PCA services combined with the plan's coordination of care with appropriate medical professionals, specialized equipment as medically appropriate, and continuous monitoring of the patient's needs in the community. The patient was hospitalized with a urinary tract infection (UTI). The patient saw her PCP for a follow-up and the PCP wrote a letter stating the patient would wake up screaming about pain in her legs and feet several times a night, the aide would wake up multiple times during the night and is not getting the 5 hours of continuous sleep which by law they must have, and prior to the patient's bedtime routine, if she has a bowel movement, it causes her to go into a delirium state, and it was imperative that the aide must be by her side during these episodes. The insurer provided a case summary. The patient's PCP appealed the denial decision, noting on the denial form that the patient was unable to turn herself, must be repositioned every 2 hours, had recurrent bedsores even with the use of an air mattress, most recently was hospitalized with a UTI, and required her diaper to be changed every 2 hours. The patient's PCP provided another letter, stating the patient had frequent urinary tract infections, night terrors, and the need for repositioning. The PCP stated the notice was to emphasize the need of her care in the evening and night logs reflected that aides do not get the required by law 5 hours a night sleep. Lastly, the PCP letter stated it was imperative that the patient received two 12-hour shifts.

At issue is the medical necessity of personal care worker (PCW) services, 7 days per week, 24 hours per day, continuous care by more than 1 person, 168 hours per week.

Yes, the services are medically necessary. 

There is documentation from the patient's PCP and from the assessment of worsening cognitive function. The patient's PCP also noted worsening functional status with recurrent decubitus ulcers. The patient had a subsequent hospitalization 3 months after her last assessment with further decline in functional status. Although the patient had overnight behavior issues, she required assistance with ADLs in the overnight hours such that a PCA would not be able to obtain 5 hours of uninterrupted sleep. The patient's PCP recommended frequent changing of diapers due to recurrent UTI and turning and repositioning at least every 2 hours because of decubitus ulcers. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, continuous, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.