Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, coronary artery disease, hypertension, heart failure, chronic obstructive pulmonary disease (COPD), and atrial fibrillation.

Treatment: Personal Care Worker (PCW) services of 7 days per week, 12 hours per day for a total of 84 hours per week.

The insurer denied coverage for PCW services of 7 days per week, 12 hours per day for a total of 84 hours per week.

The denial is overturned. 

This is a female patient who has multiple medical conditions associated with functional decline for daily activities. She lives alone. The patient had been receiving personal care worker (PCW) services 38 hours per week. The patient (via designee) requested increase of PCW hours to 84 hours per week (12 hours per day). The request was denied by the insurer, but the insurer increased PCW services to 42 hours per week (6 hours per day). 

Uniform Assessment System (UAS) documentation was provided for review.  The insurer's final denial letter indicates the patient was discharged from a hospital approximately 11 months after the completion date of this UAS report. It was noted in the insurer's letter that the insurer reviewed some hospital documentation, but no hospital records were provided for this review, and the final denial letter did not describe any details of the hospitalization. Based on the recent letters from the patient's physician and community friend (designee for the patient) it appears there have been some changes in the patient's medical condition and functional status since the UAS report. The information provided in the UAS report can be used as a reference for the patient's medical history and as a baseline for her functional ability with daily activities; but does not necessarily reflect the patient's current medical and functional status.

The patient's functional status as reported in the UAS report included the following: For instrumental activities of daily living (IADLs), the patient needed maximal assistance for meal preparation, housework and shopping; extensive assistance for phone use, stairs and transportation; and limited assistance to manage medications and finances. For activities of daily living (ADLs), she needed extensive assistance for bathing and lower body dressing; limited assistance for all other ADLs. Assessment of cognitive status was limited; noted as oriented x 3; forgetful at times; decision making for daily tasks was modified independence (some difficulty in new situations). The patient's medical history, as reported in the UAS report, and information from the physician and community friend provide probable contributing causes to the patient's physical functional decline; these include: osteoarthritis, coronary artery disease, hypertension, heart failure, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. Considering the patient's medical history, prior level of function at the time of the UAS report and current information provided by the physician and community friend, it is apparent that the patient needs substantial assistance for most IADLs and ADLs.  Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day to provide assistance for daily activities.

The patient has substantial functional impairment and needs assistance for all daily activities in her home from morning until she goes to bed at night. There are also concerns for her health and safety during the night. PCW services 7 days per week, 12 hours per day; 84 hours per week is medically necessary. Re-assessment will determine whether PCW services 12 hours per day is sufficient to meet the patient's daily care needs.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for PCW services of 7 days per week, 12 hours per day for a total of 84 hours per week is overturned.