Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, gastroesophageal reflux disease, bladder incontinence, gout, insomnia, localized edema, abnormality of gait and mobility, osteoarthritis. 

Treatment: Personal care worker (PCW) services of 6 hours per day, 7 days per week for a total of 42 hours. 

The insurer denied coverage for personal care worker (PCW) services of 6 hours per day, 7 days per week for a total of 42 hours. 

The denial is overturned. 

This patient has functional impairment due to several medical conditions and needs assistance with multiple daily activities. He lives alone. He receives some informal help from family but mostly relies on personal care worker (PCW) services for help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). He is currently receiving PCW services 28 hours per week. The patient (via designee) requested increase of services to 42 hours per week (increase from 4 hours per day to 6 hours per day), which was denied. External appeal was requested. 

The patient has urinary incontinence, which is reported as occasional in the UAS (uniform assessment system); but there is some concern that occurrence may be more frequent. The UAS diagnosis list indicates patient has functional incontinence, which is incontinence occurring as a result of delay in reaching a toilet. A common cause of functional incontinence is impaired mobility. The patient has difficulty with transfers and walking suggesting that he may have difficulty standing up and walking to the bathroom, which may result in episode of incontinence. The daughter also reported that the patient needs assistance changing pullups, which is consistent with his need for assistance with lower body dressing. 

The information provided for review indicates the patient needs assistance for various activities throughout the day. Therefore, it is medically necessary, and in the patient's best interest, to have a caregiver present for a more extended period of the day to provide assistance with ADLs and IADLs during hours the patient is most active. Additional PCW hours would accommodate more of the patient's need for assistance with mobility and toileting related tasks, which occur at various and unscheduled times during the day. It can also provide additional help for meals and possibly (if hours are split) assistance with morning and evening ADLs. 

The UAS identified two informal caregivers; only one provided ADL and IADL care in the previous 3 days (3 hours). Assistance from the informal caregiver may continue but may not necessarily provide the same level of care as the PCW and may not be available on a consistent basis every day.  Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. Considering the request for PCW services is for 6 hours per day, 7 days per week, it is reasonable to conclude that there are no informal caregivers who are able to provide care during these hours on a regular basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance for daily activities. Additional PCW hours per day will provide more support to the patient during hours of the day when he is most active. Daily schedule of PCW hours will be determined with the patient and (if needed) the family. 

Personal Care Worker services 7 days per week, 6 hours per day, 42 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the requested Personal Care Worker (PCW) Services of 6 hours per day, 7 days per week for a total of 42 hours is overturned. Medical necessity is substantiated.