Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe cognitive impairment. 
Treatment: 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week of Personal Care Worker services. 

The insurer denied coverage for 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week of Personal Care Worker (PCW) services. 

The denial is overturned. 

The patient underwent a uniform assessment (UAS).  The patient lives alone in a 1-bedroom apartment.  The patient was alert and oriented but forgetful at times.  The patient was usually understood and usually able to understand others.  The patient had word finding difficulty or finishing thoughts but could complete them if given time.  The patient was totally dependent for meal preparation, ordinary housework, required maximal assistance with managing finances, and required extensive assistance with managing medications and telephone use.  The patient was totally dependent for stairs and required maximal assistance for shopping.  The patient was totally dependent for transportation.  The patient required maximal assistance with bathing, dressing of the lower body, and toilet use.  The patient required extensive assistance with dressing of the upper body and personal hygiene.  The patient was totally dependent for locomotion.  Extensive assistance was required for bed mobility and limited assistance was needed for eating.  The patient's locomotion was with the use of wheelchair/scooter.  The patient would wet the bed and needed to have a bed bath every morning.  There was frequent incontinence of bowel and bladder.  There was dyspnea when performing moderate activities.  There was moderate fatigue due to diminished energy.  The patient had mild pain symptoms that were exhibited daily in the last 3 days.  The patient had pressure ulcers on the buttocks.  A wound care nurse came every other day to see the patient. 

A Mini-Mental status examination noted a total score of 14 falling within the severe cognitive impairment range.  The patient was alert and oriented x2.  The patient was forgetful.  The right hand had acquired missing 3 fingers and the patient was not able to draw or write. 

Per the referenced guidelines, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support.  To qualify for a split shift or continuous personal care services, the patient must require uninterrupted care by more than one personal care aide for more than 16 hours in a calendar day with tasks such as toileting, walking, transferring, turning, or positioning with such frequency that an in-living 24-hour personal care aide would not be able to obtain on a regular basis 5 hours daily of uninterrupted sleep during the 8-hour sleep. The patient is noted to have significant decline, cognitive dysfunction, incontinence, bed-bound status and significant wounds requiring home health wound care management.  The patient requires repositioning of such frequency to prevent further skin breakdown that would not allow a live-in 24-hour personal care aide to obtain on a regular basis 5 hours of daily uninterrupted sleep.  The patient is also noted to have cognitive decline which could result in unpredictable day and night behavioral.  Thus, the denial of coverage for 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week of PCW services is overturned. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  

The medical necessity for 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week of PCW is substantiated.