Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Memory loss, heart failure, Alzheimer's disease
Treatment: Increase Personal Care Worker (PCW) Services to 7 Days per Week, 24 Hours per Day, Continuous Care by More Than One Person, 168 Hours per Week
The insurer denied: Increase Personal Care Worker (PCW) Services to 7 Days per Week, 24 Hours per Day, Continuous Care by More Than One Person, 168 Hours per Week
The denial is overturned.

This elderly female patient has conditions including memory loss, heart failure, Alzheimer's disease, hypertension, chronic obstructive pulmonary disease (COPD), and foot pain.  She is appealing denial of increase in personal care worker (PCW) services to seven days per week, 24 hours per day, continuous care by more than one person, 168 hours per week. The plan approved personal care worker (PCW) seven days per week, six hours per day, for a total of 42 hours per week.
Appeal statements note the patient needs total assistance with activities of daily living (ADLs) and frequent bathroom use, including five to six times per night.  She has been prescribed diuretics with result in frequent bathroom use.  She needs assistance with ambulation, transferring, and toileting.  Her physical and mental health are worsening.  She has no informal support.  She has cognitive disability with confusion and poor memory.  She has a history of falling.

The proposed treatment 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.

This patient has multiple chronic conditions.  She is appealing denial of increase in personal care worker (PCW) services to seven days per week, 24 hours per day, continuous care by more than one person, 168 hours per week. The plan approved personal care worker (PCW) seven days per week, six hours per day, for a total of 42 hours per week.  The plan denied an increase in hours based on an evaluation showing the patient can toilet with help, transfer with limited help, and feed herself.  Several appeal statements have been provided.  These statements show the patient needs assistance with activities of daily living and frequently uses the bathroom due to prescription medications.  Her health is deteriorating, and she needs assistance with ambulation and transferring.  The statements support the patient needs assistance with activities of daily living and requires frequent assistance with toileting during day and night.  This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift.  The approved personal care worker service seven days per week, six hours per day, for a total of 42 hours per week is insufficient to meet the patient's needs for assistance.  The proposed personal care worker services to seven days per week, 24 hours per day, continuous care by more than one person, 168 hours per week, is medically necessary.