Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, depression, anxiety, shortness of breath, osteoporosis, neuropathy, and urinary incontinence.
Treatment: Increase Personal Care Worker (PCW) Services From 84 Hours Per Week To 7 Days Per Week, 24 Hours Per Day, Live-in; A Total 91 Hours Per Week.
The insurer denied the Increase Personal Care Worker (PCW) Services From 84 Hours Per Week To 7 Days Per Week, 24 Hours Per Day, Live-in; A Total 91 Hours Per Week.
The denial is overturned.

The patient is a female. Her medical conditions include dementia, depression, anxiety, shortness of breath, osteoporosis, neuropathy, and urinary incontinence. Denial of increase in personal care worker (PCW) services from 84 hours per week to 7 days per week, 24 hours per day, live-in, a total 91 hours per week is being appealed.

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

A letter from the patient's provider notes the patient has multiple medical conditions with progressive dementia. Notes she is unable to perform ADLs (activities of daily living) and is bedbound. She needs turning and repositioning every 2 hours. She needs frequent diaper changes. She is at risk of harm if left alone.

Yes, the increase in personal care worker to 24 hours/day, live in, is 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. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase personal care worker (PCW) services from 84 hours per week to 7 days per week, 24 hours per day, live-in, a total 91 hours per week, is being appealed.

The patient has several chronic conditions including dementia. Per UAS (Uniform Assessment System) evaluation completed, the patient requires assistance with all ADLs (activities of daily living). She has bladder incontinence. The appeal letter from her doctor notes the patient's dementia has deteriorated. Includes that she is bedbound and needs turning and repositioning every 2 hours. This patient has significant cognitive and physical impairments that are noted to be progressive. The approved PCW (personal care worker) 84 hours per week to 7 days is inadequate to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). The proposed increase in PCW (personal care worker) to 7 days per week, 24 hours per day, live-in, a total 91 hours per week is medically necessary and appropriate to meets this patient's needs for assistance with ADLs (activities of daily living) and personal care, including turning and repositioning every 2 hours.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.