Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, sarcopenia
Treatment: Increase Personal Care Worker (PCW) Services 
from 56 Hours to 7 Days per Week, 12 Hours per Day for a Total of 84 Hours per Week
The insurer denied: Increase Personal Care Worker (PCW) Services from 56 Hours to 7 Days per Week, 12 Hours per Day for a Total of 84 Hours per Week
The denial is overturned.

This elderly female has conditions that include dementia, arthritis, macular degeneration, sarcopenia, and hearing loss. Denial of increase personal care worker (PCW) services from 56 hours to 7 days per week, 12 hours per day, for a total of 84 hours per week is being appealed. 
The health plan partially approved an increase in personal care worker (PCW) services from 56 hours to 63 hours per week.
Uniform Assessment System (UAS) evaluation completed two months ago shows moderately impaired condition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, phone use, bathing, lower body dressing, and toilet use; and extensive assistance with bathing, personal hygiene, upper body dressing, bed mobility, and eating. She has bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with lower body dressing. A letter from the Provider notes the patient has rapidly deteriorating mental and physical health and functional status. She is homebound and depends on a wheelchair for mobility. She has an ataxic gait and repeated falls. She requires daily supervision, reminders, and assistance with activities of daily living (ADLs). A letter from the patient's niece notes the patient is homebound. The patient is unable to get out of bed on her own. She needs repositioning and diaper changes.

The proposed treatment 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. This patient has multiple chronic conditions. Denial of increase personal care worker (PCW) services from 56 hours to 7 days per week, 12 hours per day, for a total of 84 hours per week is being appealed. The health plan partially approved an increase in personal care worker (PCW) from 56 hours to 63 hours per week. Uniform Assessment System evaluation completed two months ago, shows the patient requires extensive assistance to total dependence with all activities of daily living. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with lower body dressing. The patient has bowel and bladder incontinence. Appeal statements note that the patient's physical and cognitive condition has declined. She is homebound and depends on a wheelchair for mobility. She is at risk for falls. The information provided shows that this patient has significant limitations in functioning. The 
approved personal care worker services 63 hours per week is insufficient to meet this patient's needs for assistance with all activities of daily living. The proposed increase to 84 hours per week is medically necessary.