Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral vascular disease (PVD), hyperlipidemia, a breast mass, hypertension, hypothyroidism, and cerebral aneurysm. 
Treatment: Personal care worker (PCW) services 7 days per week, 8 hours per day: 56 hours per week. 
The insurer denied coverage for personal care worker (PCW) services 7 days per week, 8 hours per day: 56 hours per week. 
 The denial is overturned. 

This patient has functional impairment associated with various medical conditions and needs assistance with most daily activities. She lives alone in the 2nd floor apartment of a two-family home: her daughter lives in the 1st floor apartment. The daughter provides informal help, but she works full-time. The patient relies on personal care worker (PCW) services during the day for assistance with ADLs (activities of daily living) and IADLs (instrumental activities of daily living). She has been receiving PCW services 35 hours per week (5 hours per day, 7 days per week). The patient's daughter (as designee for the patient) requested increase of PCW services to 56 hours per week (8 hours per day, 7 days per week), which was denied. An external appeal was requested. 

The most recent UAS (uniform assessment system) was reviewed. The functional status report for instrumental activities of daily living (IADLs), indicated the patient is totally dependent for housework, managing finances, and shopping; she needs maximal assistance for meal preparation, managing medications, phone use; extensive assistance for stairs, transportation. For activities of daily living (ADLs), the patient needs extensive assistance for bathing, dressing lower body, toilet use; limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, bed mobility, and eating. 

Functional decline in older people is usually the result of combined effects of various medical conditions resulting in physical and/or cognitive impairment. Other contributing factors include social and economic circumstances (e.g., caregiver support). 

MLTC (managed long term care) policy 16.07 states that managed long term care plans must assure that the plan of care can meet any of the patient's unscheduled or recurring daytime or nighttime needs for assistance. The patient needs assistance for all ADLs; some are routine (e.g., bathing, dressing, personal hygiene); some occur at unscheduled and/or recurring times during the day (e.g., mobility, toileting, eating/drinking). All of these ADL care needs must be considered in the determination of the patient's personal care service hours. This is not stand-alone safety monitoring. Lack of assistance for an extended period of time every day places the patient at risk for adverse health and safety events, including falls/injury, skin damage due to inadequate toileting and incontinence care, impaired nutrition, dehydration. Therefore, it is medically necessary to have a caregiver present for a more extended period of time each day when informal helpers are not available. The patient's daughter is the only informal helper identified in the available records. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed. The patient will benefit from an increase of PCW services to 56 hours per week. 

Recommendation is given to approve Personal Care Worker services 7 days per week, 8 hours per day: 56 hours per week. 

The insurer's denial of coverage for personal care worker (PCW) services 7 days per week, 8 hours per day; 56 hours per week is overturned. Medical Necessity is substantiated.