Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis, valvular aortic stenosis, ischemic heart disease. 
Treatment: Personal care worker (PCW) services, 7 days per week, 12 hours per day: 84 hours per week. 

The insurer denied coverage for personal care worker (PCW) services, 7 days per week, 12 hours per day: 84 hours per week. 
 
The denial is overturned. 

This case involves a female seeking authorization for coverage personal care worker services for 7 days/week for 12 hours/day for total of 84 hours/week. The patient had a history of multiple sclerosis, valvular aortic stenosis, ischemic heart disease, bradycardia, malignant neoplasm of bladder, dementia, gastroesophageal reflux disease, and major depressive disorder. It was noted that the patient lived alone and received personal care worker services. She required assistance with activities of daily living and instrumental activities of daily living. She needed extensive assistance with bathing, toilet transfers, and lower body dressing. She needed limited assistance with upper body dressing, personal hygiene, walking/locomotion, toilet use, and bed mobility. There was infrequent bowel incontinence and occasional bladder incontinence. Her capabilities have declined. Overall, her self-sufficiency had deteriorated. 

Per the cited literature, cognitive deficits are independently correlated with the burden of multiple sclerosis and should be monitored as part of routine care. The use of personal assistance is crucial for patients with disabilities to allow them to remain in the community as opposed to being placed in institutional settings.  Medical necessity services are those that will or are reasonably expected to prevent the onset of illness, condition or disability, will or are reasonably expected to reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, and disability. They will assist the patient to achieve or maintain maximum functional capacity in performing daily activities, will provide the opportunity for a patient to have access to the benefits of community living to achieve person centered goals and to live and work in the setting of their choosing. In this case, it was noted that the patient was diagnosed with multiple sclerosis and dementia. Following hospitalization for COVID-pneumonia, the patient had a significant decline in function. She had generalized weakness. It was noted that the patient needed human assistance for ambulation due to weakness in her lower extremities. She needed help with changing positions. She was incontinent of bowel at times. She has significant difficulty getting in/out of a chair. She had incontinence and was unable to dress or change herself. She required constant reminders to take her medications. A request was noted for increasing personal care assistance hours. Based on the documentation, the requested 84 hours/week are medically necessary. The patient has significant deficits in her ability to dress, toilet, and ambulate. The physical therapy notes indicate that she requires assistance for all ambulation. Having a personal care aide is not just for safety but to allow the patient to ambulate, an essential activity of daily living. This promotes strengthening and decreases risk of skin breakdown that would otherwise occur due to sedentary status as well as incontinence. As such, the denial of coverage for personal care worker (PCW) services, 7 days per week, 12 hours per day, 84 hours per week is not appropriate and is overturned. 

The insurer's denial of coverage for personal care worker (PCW) services, 7 days per week, 12 hours per day; 84 hours per week is overturned. Medical Necessity is substantiated.