Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Muscle Weakness. 
Treatment: Personal Care Worker. 

The insurer denied Personal Care Worker (PCW) Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of anxiety, depression, osteoporosis, osteoarthritis, chronic obstructive pulmonary disease (COPD), atrial fibrillation on chronic anticoagulation, chronic kidney disease stage IV, multinodular goiter, urinary incontinence, diabetes mellitus type 2, coronary artery disease, aortic valve replacement, congestive heart failure, hypertension, and cerebrovascular accident (CVA) with residual right-sided weakness who had PCW (personal care worker) services assigned based on assessment tool performed assessing the patient at total assistance with tasks of ordinary housework while maximum assistance with tasks of meal preparation, stairs, shopping, and transportation. With tasks of managing finances, managing medication, phone use, equipment management, personal hygiene, and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility and eating. 

Personal Care Worker (PCW) Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week is medically necessary for this patient.
There is documentation from multiple medical providers over the patient's worsening physical and cognitive functioning. The patient had increased care needs following COVID-19 infection and with worsening of her right knee osteoarthritis. The assessment tool noted increased care needs with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The plan assumed the patient has informal support outside of the hours of assigned PCW services. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCW services is not solely for safety and supervision but to assist the patient with safe completion of ADLs (Activities of daily living) and Instrumental activities of daily living (IADL) s. The patient's daughter noted the patient had completed physical therapy following her hospitalization and rehabilitation stay for COVID-19 and had reached maximum improvement despite the insurer recommending initiation of physical therapy following the assessment. The plan recommended a bedside commode; however, the patient still requires assistance with transferring and toilet use. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCW services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. 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.