Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, dementia
Treatment: Increase Personal Care Worker (PCW) Services 
from 56 Hours per Week to 7 Days per Week 24 Hours per Day (Live-in) 91 Hours per Week
The insurer denied: Increase Personal Care Worker (PCW) Services from 56 Hours per Week to 7 Days per Week 24 Hours per Day (Live-in) 91 Hours per Week

The denial is overturned

This elderly female patient has conditions that include diabetes, osteoporosis with lumbar compression fracture, and dementia. She had a hip fracture with hip hemiarthroplasty seven months ago. The denial of an increase in personal care worker (PCW) services from 56 hours per week to 7 days per week 24 hours per day (live-in) 91 hours per week is being appealed. 

Uniform Assessment System (UAS) evaluation completed eight months ago showed minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with phone use; extensive assistance with managing medications limited assistance with bathing, personal hygiene, and dressing; supervision with walking; and independent with bed mobility and eating. She has bowel and bladder incontinence. 

A letter from her Provider notes the patient's physical and cognitive status have declined. The patient needs assistance with activities of daily living. She needs regular monitoring of vital signs due to blood pressure fluctuation. She has dysphagia and episodes of choking. She is a falls risk. 

A statement from New York State notes the patient's needs for assistance with activities of daily living has increased since her last Uniform Assessment System evaluation. Nighttime logs show assistance with ambulating to the bathroom every one to two hours and bed transfer. The patient requires regular bathing/changing due to urinary incontinence and chronic diarrhea. Letters from the patient's providers recommend increased assistance with activities of daily living.

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding. 

This patient has multiple chronic conditions and a recent hip fracture. Denial of an increase in personal care worker (PCW) services from 56 hours per week to 7 days per week 24 hours per day (live-in) 91 hours per week is being appealed. Uniform Assessment System (UAS) evaluation completed eight months ago showed the patient needs assistance with all activities of daily living, except bed mobility and eating. She has bowel and bladder incontinence. Appeal statements indicated the member's physical and cognitive functioning have declined. The statement support need for assistance with activities of daily living (ADLs). She has urinary incontinence and chronic diarrhea. Nighttime logs show the patient requires nighttime assistance with ambulating to the bathroom every one to two hours and bed transfer. The information provided supports that the patient has needs for assistance with activities of daily living (ADLs) that cannot be met with the approved personal care worker services 56 hours per week. The proposed increase to 7 days per week 24 hours per day (live-in) 91 hours per week is medically necessary.