Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dementia, major depression, anxiety, obesity, colon cancer, colon resection, coronary artery disease
Treatment personal care worker (PCW) services of 7 hours per day, 7 days per week
The insurer denied coverage for personal care worker (PCW) services of 7 hours per day, 7 days per week
The denial is overturned

The patient is a female with a past medical history of Parkinson's disease, dementia, major depression, anxiety, obesity, colon cancer, colon resection, coronary artery disease, hypertension, insomnia, degenerative joint disease and loss of memory. A letter dated indicated the patient's cognitive functions were impaired due to the primary medical and psychiatric conditions. The patient was also taking psychotropic medication that further affected reasonable judgment. The patient was having frequent episodes of confusion and disorientation in time and place. She was having significant difficulty walking, problems with balance, and frequent falls. The patient required constant supervision and help with washing, bathing, toileting, shopping, meal preparation and laundry. It was the opinion of the provider that due to the mental and medical conditions the patient required home health service 7 days a week, 10 hours a day.

The letter from the psychiatric provider indicated that the patient presented with worsening memory, paranoia, confusion, a depressed and anxious mood, fear of falls, fear of being alone, and disorganized thinking and behavior. The patient had a suicidal attempt with clonidine overdose in the setting of severe treatment resistant depression. She continued to have depression, poor activities of daily living (ADLs), was unable to take care of herself. She forgot to eat and had increased episodes of wandering and confusion at night. It was recommended the patient have 24-hour day, 7-day a week care. 
 
The New York State Department of Health's Uniform Assessment System (UAS-NY), noted that the patient lives alone in an apartment building and the patient's daughter is involved in her care. The patient is totally dependent for meal preparation and ordinary housework. The patient needs maximum assistance with managing stairs and shopping, transportation and needed extensive help with bathing and dressing her lower body. She needed limited assistance with managing finances, managing her medications, phone use, personal hygiene, dressing her upper body, walking, eating, locomotion with the walker, toilet transfer and toilet use. The patient was occasionally bladder incontinent but has complete bowel control. She needed setup help only with bed mobility.

Based on the clinical information provided it appears that this patient is declining rapidly in her cognition and physical mobility and is at great risk for falls and other severe injuries if she is left alone for too long. 

There was sufficient evidence to support that PCW services for 7 hours per day, 7 days per week was considered medically necessary treatment for the patient's condition.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for personal care worker (PCW) services of 7 hours per day, 7 days per week is reversed. Medical necessity is substantiated.