Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cataracts, hypertension, breast cancer, gastroesophageal reflux disease (GERD), hyperlipidemia, and osteoarthritis

Treatment: Personal Care Worker (PCW) services 7 days per week, 8 hours per day; 56 hours per week

The insurer denied coverage for PCW services 7 days per week, 8 hours per day; 56 hours per week

The denial is overturned

This patient has extensive medical history associated with functional impairment for daily activities. The patient lives alone. She receives some informal help from her family, but mostly depends on PCW services for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She had been receiving PCW services 33 hours per week. An increase of PCW services to 56 hours per week was requested, which was denied; but the insurer increased services to PCW 35 hours per week (7 days per week, 5 hours per day). External appeal was requested for PCW services 56 hours per week.

The most recent Uniform Assessment System (UAS) report was reviewed. Functional status report for IADLs, indicated the patient is totally dependent for meal preparation, ordinary housework, managing finances; she needs maximal assistance for transportation, shopping, phone use; extensive assistance for stairs, managing medications, equipment management. For 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; supervision for eating.

The UAS and physicians' letters indicate the patient has dementia; identified by the psychiatrist as vascular type. The psychiatrist reported increasing problems with memory, concentration, and comprehension. The UAS describes the patient's decision making for daily tasks as moderately impaired (decisions consistently poor or unsafe, cues/supervision needed at all times); she was oriented x 2, forgetful, confused at times. As per UAS, patient has short term, procedural, and situational memory problem. Mini-Mental State Examination (MMSE) score was 9, (borderline moderate to severe cognitive impairment). It was noted on the MMSE form patient has hearing impairment. It is not clear whether this interfered with the patient's performance on the MMSE. The patient's communication ability for expression was noted as difficulty finding words and finishing thoughts; needs prompting. For comprehension, she misses some intent of message, but with explanation and repetition, she can often understand conversation. 
Regarding behavioral issues, UAS noted patient resists care at times (e.g., shower, medications). There is a history of wandering, but not recently. 

Current PCW services are 5 hours per day. The patient needs assistance for all toileting related tasks (which occurs throughout the day), and so, she needs to have a caregiver present for a more extended period of time each day to assist with toileting related care. 
Based on the information provided for review, the patient needs assistance with activities that occur at routine and unscheduled times during the day, and the care plan needs to accommodate these care needs. It is medically necessary, and in the patient's best interest to have a caregiver present over a longer period of time each day to provide assistance with daily activities in order to prevent adverse health and safety events, such as falls/injury, skin damage and urinary tract infection (UTI) from inadequate incontinence care, impaired nutrition, dehydration.

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 7 days per week, 8 hours per day; 56 hours per week is reversed. Medical Necessity is substantiated.