Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, hypertension, anemia, coronary artery disease, hip and shoulder pain, incontinence, weakness, fatigue, dizziness, weakness, and Parkinson's disease. 
Treatment: Increase Personal Care Worker (PCW) Services to 9 Hours Per Day, 7 Days a Week. 

The insurer denied: Increase Personal Care Worker (PCW) Services to 9 Hours Per Day, 7 Days A Week. 
The denial is overturned. 

This older adult female has multiple conditions including osteoarthritis, hypertension, anemia, coronary artery disease, hip and shoulder pain, incontinence, weakness, fatigue, dizziness, weakness, and Parkinson's disease. She had a recent admission for altered mental status. 
The patient is appealing denial of increase personal care worker (PCW) services to nine (9) hours per day, seven (7) days a week. The health plan approved six (6) hours per day, seven (7) days a week. Uniform Assessment System (UAS) evaluation shows moderately impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, phone use, bathing, lower body dressing, and toilet use; limited assistance with personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and bed mobility; and supervision with eating. She has occasional bladder incontinence. The Uniform Assessment System (UAS) evaluation completed recently shows no significant change in functioning. 
A letter from the patient's internal medicine provider states the patient needs constant personal assistance in all her activities of daily living (ADLs) due to recent deterioration. 
A letter from the patient's neurologist states the patient exhibits delirium each evening, memory loss, insomnia and frequent awakenings. She has ataxia. Assistance is recommended 12 hours per day. 

The proposed treatment, personal care worker (PCW) services, nine (9) hours per day, seven (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 with multiple chronic conditions is appealing denial of increase personal care worker (PCW) services to nine (9) hours per day, seven (7) days a week. The health plan approved six (6) hours per day, seven (7) days a week. The Uniform Assessment System (UAS) evaluation shows the patient requires assistance with all activities of daily living (ADLs), except eating. She also has bladder incontinence. 

The appeal statements indicate the patient's medical status is deteriorating and she needs assistance with all activities of daily living (ADLs). The patient's physical functioning is significantly impaired, and she requires significant assistance with activities of daily living (ADLs). The need for assistance with all activities of daily living (ADLs) cannot be met with the approved personal care worker (PCW) services six (6) hours per day, seven (7) days a week. Therefore, the proposed increase to personal care worker (PCW) services, nine (9) hours per day, seven (7) days a week is medically necessary.