Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, diabetes mellitus, stroke/CVA (cerebral vascular accident), difficulty walking, hypertension, functional urinary incontinence, history of falling, generalized muscle weakness, fatigue, right hip pain, generalized osteoarthritis, bilateral hearing loss, unsteadiness on feet, and wandering. 
Treatment: Increase in personal care worker (PCW) services to 7 days per week, 24 hours per day split shift of continuous care by more than one person; 168 hours per week. 

The insurer denied coverage for increase in personal care worker (PCW) services to 7 days per week, 24 hours per day split shift of continuous care by more than one person; 168 hours per week. 

The denial is upheld. 

This is a geriatric patient with medical problems that include heart disease, stroke, diabetes, and dementia. The patient lives alone in a private residence. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as minimally impaired. The patient requires maximal assistance for Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient requires extensive assistance for bathing, personal hygiene, and dressing. Limited assistance is needed for bed mobility, locomotion, ambulation, and toilet transfer/use. The patient is occasionally incontinent of bladder and continent of bowel. 

The patient sustained a right hip fracture and after hospitalization was transferred to a skilled nursing facility. The patient received physical and occupational therapy. The therapy notes document substantial functional improvement. According to the occupational therapy notes, the patient was at the "setup" level of assistance for oral hygiene and upper body dressing. The patient required moderate assistance for toilet hygiene, bathing, and lower body dressing. The physical therapist noted similar functional improvement. 

This physician agrees with the insurer increasing PCW from 35 hours/week to 7 days/week, 24 hours/day live-in: 91 hours/week. The patient's clinical condition, cognition and functional deficits are not at a level and unpredictable as to require the requested 7 days per week, 24 hours per day split shift of continuous care by more than one person: 168 hours per week. This physician would also agree the patient may require additional monitoring, particularly due to her cognitive decline and history of wandering. However, safety monitoring under Personal Care Services (PCS) does not include monitoring an individual (such as with dementia/wandering) when no other Level I or Level II personal care service tasks are being provided. Based on the records reviewed, attention to the patient functional needs is appropriately provided and maintained by the approved PCW 7 days/week, 24 hours/day live-in: 91 hours/week. 

Based on the above, the insurer's denial must be upheld. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in personal care worker (PCW) services from 7 days per week, 5 hours per day; 35 hours per week to 7 days per week, 24 hours per day split shift of continuous care by more than one person; 168 hours per week is not substantiated. This physician agrees with the insurer increasing PCW from 35 hours/week to 7 days/week, 24 hours/day live-in: 91 hours/week.