Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Personal Care Worker (PCW) Services to 7 Days Per Week, 24 Hours Per Day Continuous Care by More Than One Person: A Total of 168 Hours Per Week
The insurer denied: Increase Personal Care Worker (PCW) Services to 7 Days Per Week, 24 Hours Per Day Continuous Care by More Than One Person: A Total of 168 Hours Per Week
The denial is overturned.

The patient is an elderly female with a history of general debility due to dementia. The request is for Personal Care Assistance through Home Health care (Level 2) to be increased from 63 hours per week (9 hours per day, 7 days per week) to 168 hours per week (24 hours per day, 7 days per week) based on UAS (Uniform Assessment System) evaluation conducted some months ago.
The health plan denied coverage of the request, citing that the patient is able to ambulate, transfer, and use the toilet with assistance (not noting the level of assistance required). They note that the patient is able to feed herself, is alert and oriented to person and place with confusion, while she is also able to make her needs known and able to summon help in case of emergency. They further note that the inability to sleep at night is not a need that can be met by using personal care assistance.
The additional hours requested are because of the patient's chronic medical conditions, and to help with her Activities of Daily Living (ADLs), as she is moderately impaired cognitively, with decisions consistently poor or unsafe, and supervision is required at all times. She requires extensive assistance for phone use, personal hygiene, upper body dressing, walking, toilet transfer, toilet use, bed mobility, eating, maximal assistance for managing medications, bathing, lower body dressing, locomotion, and total dependence for meal preparation, housework, managing finances. She is also incontinent of bowel and bladder. She lives alone in a 1-bedroom apartment. A review of the records shows that the patient has multiple chronic medical conditions, including Dementia, CAD (coronary artery disease), Depression, CHF (congestive heart failure), cardiac arrhythmia, hypertension, frequent falls, insomnia, anemia, glaucoma, arthritis, hyperlipidemia, melanoma, hypothyroidism, TIA (transient ischemic attack), on Eliquis, etc. The patient's UAS (Uniform Assessment System) evaluation of some months ago showed that she is moderately impaired cognitively, with decisions consistently poor or unsafe, supervision required at all times. She requires extensive assistance for phone use, personal hygiene, upper body dressing, walking, toilet transfer, toilet use, bed mobility, eating, maximal assistance for managing medications, bathing, lower body dressing, locomotion, and total dependence for meal preparation, housework, managing finances. She is also incontinent of bowel and bladder. The patient lives alone in a rented 1-bedroom apartment.

The requested Increase Personal Care Worker (PCW) Services to 7 Days Per Week, 24 Hours Per Day Continuous Care by More Than One Person: A Total of 168 Hours Per Week is medically necessary.

Based on the most recent UAS (Uniform Assessment System) evaluation several months ago, she is moderately impaired cognitively, with decisions consistently poor or unsafe, and supervision is required at all times. She requires extensive assistance for phone use, personal hygiene, upper body dressing, walking, toilet transfer, toilet use, bed mobility, eating, maximal assistance for managing medications, bathing, lower body dressing, locomotion, and total dependence for meal preparation, housework, managing finances. She is also incontinent of bowel and bladder. The reason cited by the health plan in their denial, as noted in the clinical information above, does not align with the patient's disability features as stated in the UAS (Uniform Assessment System)  as stated above. Therefore, the 168 hours per week (24 hours per day, 7 days per week) based on UAS (Uniform Assessment System) conducted several months ago is medically necessary.