Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Worker (PCW) Services for 7 days per week, 10 hours per day for a total of 70 hours per week
The insurer denied the request for PCW Services for 7 days per week, 10 hours per day for a total of 70 hours per week.
The health plan's determination is overturned.

The patient is a female with a past medical history of breast cancer, osteoarthritis, hypertension, coronary artery disease, peripheral artery disease, rheumatoid arthritis, cognitive decline and congestive heart failure. She also has a medical history of hyperlipidemia, asthma, depression, anxiety, gastroesophageal reflux disease (GERD), osteoporosis, and urinary incontinence. She was assigned PCW services for 5 hours a day, 7 days a week based on an assessment performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping. She was assessed at extensive assistance with tasks of managing medication, stairs, transportation, equipment management, bathing, personal hygiene, dressing upper and lower body, and toilet use. With tasks of managing finances, phone use, walking, locomotion, transfer toilet, and eating the patient was assessed at limited assistance while independent with task of bed mobility.

There was a request to increase PCW services and the patient underwent another assessment via video assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping. She was assessed at extensive assistance with managing finances, managing medication, phone use, stairs, transportation, equipment management, bathing, personal hygiene, dressing upper and lower body, and toilet use. With the tasks of walking, locomotion, transfer toilet, and eating the patient was assessed at limited assistance and independent with the task of bed mobility. Notes from the assessment stated the patient lived alone. 

The patient's medical provider sent a letter stating the patient was under their care and writing to ask for an urgent increase of home care hours due to the patient's accelerated decline in mental, physical, and functional status based on their clinical findings and relevant medical history. The provider noted that patient's chronic and debilitating medical conditions worsened after a recent illness with Coronavirus (COVID-19). In addition, the provider stated the patient has had multiple falls with fractures and was incontinent of urine and required assistance with diaper changes multiple times throughout the day to prevent skin irritation, rashes, and other related skin infections due to prolonged exposure to urine. In addition, the provider letter stated the patient required assistance multiple times throughout the day with eating ice sitting upright to feed herself caused severe pain due to lumbar fracture.  

There is documentation from the patient's medical provider of worsening cognitive and physical functioning. There is documentation from the patient's medical provider of medical necessity of increased service hours. The patient requires at least limited assistance with walking, locomotion, toilet transfers, and toilet use and therefore she has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient would require assistance outside of the time that she has informal help. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home. 

The health plan's determination is overturned in whole.