Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Physical and cognitive impairment. 
Treatment: Personal Care Worker (PCW) services of 7 days per week, 24 hours per day live-in for an additional 91 hours per week. 

The insurer denied coverage for PCW services of 7 days per week, 24 hours per day live-in for an additional 91 hours per week. 

The denial is overturned. 

This is a female patient who has an extensive medical history associated with physical and cognitive impairment. Her past medical history includes anemia, congestive heart failure, type 2 diabetes mellitus, gastroesophageal reflux disease, bilateral knee replacements, hyperlipidemia, hypertension, hypothyroidism, obesity, restless leg syndrome, cognitive decline, and sciatica. The patient receives personal care worker (PCW) services 56 hours per week, 8 hours per day. The patient lives in a private home on the 1st floor and her son lives upstairs.  As per the physician's letter, the patient's son has health problems which limit his ability to provide assistance to his mother.  The patient's daughter does not live with the patient; she provides some activities of daily living (ADLs) and instrumental activities of daily living (IADLs) assistance.  The patient's family has requested live-in PCW services.  

Uniform Assessment System (UAS) documentation was provided for review.  The functional status report for IADLs indicates total dependence for housework; maximal assistance for most other IADLs; except phone use (extensive assistance).  The patient needs maximal or extensive assistance for all ADLs; including maximal assistance for walking and toileting. 

Based on the patient's medical history and functional status, it is medically necessary for the patient to have assistance with all daily activities; and with very limited informal help (as per UAS and the physician's letter), she is dependent on personal care services for all ADLs and IADLs.  Although it cannot be definitively determined how often the patient needs help at night, it is medically necessary for the patient to have caregiver assistance for ADLs at various times of the day and night to prevent adverse health and safety events. The available records do not identify informal caregivers who can provide sufficient and consistent care when the PCW is not present.  As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary.  When informal caregivers are unable to provide necessary care when needed on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed throughout the day and night. 

With live-in services, the patient will benefit from additional ADLs assistance during the evening/night hours that is not available to her with her current services (PCW 8 hours per day). The live-in aide will be able to identify the patient's evening and nighttime ADL needs. 

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

The insurer's denial of coverage for the requested PCW services of 7 days per week, 24 hours per day live-in for a total of 91 hours per week is overturned. Medical necessity is substantiated.