Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, hypertension, hyperlipidemia

Treatment personal care worker (PCW) services of 7 days per week, 8 hours per day for a total of 56 hours per week

The insurer denied coverage for personal care worker (PCW) services of 7 days per week, 8 hours per day for a total of 56 hours per week

The denial is overturned

This elderly female has experienced functional decline related to her medical conditions, and probably also due to a significant change in her home/family life. Patient history of dementia with report of further cognitive decline in past few months. She had been living with her spouse. As per information from the son to the neurologist, the patient's cognitive decline became worse around the time the husband left the home. There is concern from family and medical providers as to whether the patient can safely and properly manage daily activities. The patient has been receiving assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through personal care worker (PCW) services 4 hours per day, 7 days per week, 28 hours per week. 

The most recent UAS (Uniform Assessment System) provided for review was done. The functional status report indicates patient needs maximal assistance with housework and shopping, extensive assistance with meal preparation; limited assistance with managing finances and medications, stairs, transportation; setup help with phone use. For ADLs, the patient needs limited assistance with bathing and toilet use; setup help with personal hygiene, dressing upper/lower body, transfer toilet, bed mobility, eating. Walking and locomotion are noted as independent. 

Functional decline in the elderly is generally due to the combined effects of various medical conditions resulting in physical and/or cognitive impairment.  Other factors include social and economic circumstances, including availability of caregiver support. 

The UAS identifies the patient's son as the only informal caregiver. At the time of the UAS, it was noted he provided 6 hours of care over the previous 3 days. It is not known whether and to what extent the son can continue to provide informal help. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. Considering the request for PCW services is for 8 hours per day, 7 days per week, it is reasonable to conclude that there are no informal caregivers who are able to provide care during these hours on a regular basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance for daily activities. Additional PCW services will provide more support to the patient during hours of the day when she is most active, including IADLs, routine ADLs (bathing, dressing, personal hygiene), toileting when needed through the day; and assistance/supervision for all meals. Discussion with the patient and her son will help determine whether PCW 8 consecutive hours or split into two shifts will provide the most benefit. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Personal Care Worker (PCW) Services of 7 days per week, 8 hours per day for a total of 56 hours per week is overturned. Medical Necessity is substantiated.