Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension, osteoarthritis, osteoporosis, breast cancer, lung cancer, dementia, hearing loss, dizziness, and unsteady gait
Treatment: Personal Care Worker (PCW) 24 hours live- in service per day, 7 days a week
The insurer denied the Personal Care Worker (PCW) 24 hours live- in service per day, 7 days a week
The denial is upheld.

The patient is a female. Her conditions include hypertension, osteoarthritis, osteoporosis, breast cancer, lung cancer, dementia, hearing loss, dizziness, and unsteady gait. She was hospitalized with pneumonia and with CHF (congestive heart failure) exacerbation and urinary tract infection. She lives alone. Denial of an increase in PCW (personal care worker) services to 24 hours per day, 7 days/week, is being appealed. The health plan approved increase from 8 hours per day to 12 hours per day.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with phone use; extensive assistance with managing medications, bathing, personal hygiene, dressing, and toileting; limited assistance with walking and locomotion; and supervision with bed mobility and eating. The patient has bowel and bladder incontinence.

A letter from the patient's provider notes that the patient's dementia is progressing. The patient needs help with transferring form bed to walker and wheelchair. She needs help at night with the bathroom and fell twice. She needs an aide to remind her to take her evening medications. She does not have informal support. She wakes up at night, opens doors and windows, and rings neighbor doorbells.

A letter from another provider notes that the patient's condition has destabilized and that the patient has cognitive and functional decline, which is dangerous. She is sometimes confused and exhibits psychotic symptoms. She has frequent wakening.

Medical records are provided supporting the need for assistance with ADLs (activities of daily living) as already accounted for in the UAS (uniform assessment system) evaluation.

No, the requested increase in PCW (personal care worker) Services to 24 hours/day, 7 days/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. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. There was a denial of an increase in PCW (personal care worker) services to 24 hours per day, 7 days/week. The health plan approved increase from 8 hours per day to 12 hours per day.

This patient has multiple chronic medical conditions. Uniform Assessment System (UAS) evaluation completed shows she needs assistance with all ADLs (activities of daily living), except bed mobility and eating. Medical records and physician letters support there has been a cognitive and functional decline. She exhibits confusion and psychotic symptoms. She frequently awakens and is described as wandering. She is noted to be in danger to be left unsupervised. The information provided does to support tasks being performed that require 24 hour care. PCW (personal care worker) service is not indicated for management of chronic medical conditions or for supervision. The health plan's increase in PCW (personal care worker) hours from 8 to 12 hours per day is appropriate for this patient's needs with ADLs (activities of daily living). The requested increase in PCW (personal care worker) to 24 hours per day, 7 days/week is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The requested Increase PCW (personal care worker) Services to 24 hours/day, 7 days/week is not medically necessary.