Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, hypertension, coronary artery disease, irritable bowel syndrome, anxiety, depression, and chronic dizziness
Treatment: Increase Personal Care Worker (PCW) Services, 12 Hours A Day, 7 Days A Week
The insurer denied: Increase Personal Care Worker (PCW) Services, 12 Hours A Day, 7 Days A Week
The denial is overturned.

The patient is an elderly female. Her medical conditions include osteoarthritis, hypertension, coronary artery disease, irritable bowel syndrome, anxiety, depression, and chronic dizziness. She is status post recent ORIF (open reduction internal fixation) for right hip fracture and was discharged to home. Denial of increase personal care worker (PCW) services to 12 hours a day, 7 days a week is being appealed. The health plan approved personal care worker (PCW) services 8 hours, 7 days a week.

Uniform Assessment System (UAS) evaluation performed shows independent cognition and functional status: total dependence with housework and transportation; maximal assistance with meal preparation, shopping, bathing, lower body dressing, walking, locomotion and toileting; extensive assistance with personal hygiene and bed mobility; limited assistance with managing finances, and medications and eating; and supervision with phone use. The patient uses a wheelchair and scooter for locomotion. She has frequent bladder incontinent. Compared to UAS (uniform assessment system) evaluation performed four months earlier, there has been a decline in functioning with housework, managing finances and medications, transportation, bathing, personal hygiene, dressing, walking, locomotion, toileting, bed mobility, and eating.

An appeal statement from the patient's provider notes the patient's conditions have progressed. The patient has chronic back and multiple joint pain. She has severe problems with mobility related to right hip pain. She is forgetful. She lives alone and has no informal support. She needs assistance with ADLs (activities of daily living). An appeal statement from the patient's daughter notes the patient needs assistance with ADLs (activities of daily living). Day/night logs for hours 8 AM - 4 PM are provided for review.

The requested Increase Personal Care Worker (PCW) Services to 12 Hours A Day, 7 Days A Week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. The patient has multiple chronic conditions, including recent right hip fracture. Denial of increase personal care worker (PCW) services to 12 hours a day, 7 days a week is being appealed. The health plan approved personal care worker (PCW) services 8 hours, 7 days a week.

Uniform Assessment System (UAS) evaluation performed recently shows the patient requires assistance with all ADLs (activities of daily living), except phone use. She has frequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation performed four months earlier, there has been a significant decline in the patient's level of functioning. Appeal statements indicated that there has been a decline in the patient's medical condition. She lives alone and has no informal support. This patient's physical functioning is significantly impaired and has progressed between UAS (Uniform Assessment System) evaluations. The patient's need for assistance with all ADLs (activities of daily living) cannot be met with the approved PCW (personal care worker) services 8 hours, 7 days a week. The requested increase to PCW (personal care worker) to 12 hours a day, 7 days a week is medically necessary and appropriate.