Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High grade glioma

Treatment: Personal Care Worker (PCW) 7 days per week, 24 hours per day, continuous care by more than 1 person, when mutual spouse is out of the community, and 7 days per week, 20 hours per day, continuous care by more than 1 person, when mutual spouse is in the community

The insurer denied coverage for Personal Care Worker (PCW) 7 days per week, 24 hours per day, continuous care by more than 1 person, when mutual spouse is out of the community, and 7 days per week, 20 hours per day, continuous care by more than 1 person, when mutual spouse is in the community

The denial is overturned.

This is an elderly patient with end stage progressive high-grade glioma. He lives in a private home with his spouse. The insurer approved personal care worker (PCW) 7 days per week, 6 hours per day, for a total of 42 hours per week. The request is for PCW 7 days per week, 24 hours per day, continuous care by more than 1 person, when mutual spouse is out of the community, and 7 days per week, 20 hours per day, continuous care by more than 1 person, when mutual spouse is in the community.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "minimally impaired."  He is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. Maximal assistance is needed for bathing. Extensive assistance is needed for personal hygiene, eating, dressing, locomotion, ambulation and toilet transfer/use. He has a supra-pubic bladder catheter and is infrequently incontinent of bowel. Limited assistance is needed for bed mobility.

The patient's functional ability is much the same when compared to the prior UAS report. The UAS reports; particularly the latter report does not adequately capture the rapid progression of the patient's clinical demise and terminal prognosis. The associated medical records document the patient's rapid clinical, cognitive and functional decline.  A brain magnetic resonance imaging (MRI) scan demonstrated a right parieto-occipital mass consistent with a high-grade glioma. His functional ability initially improved with high dose steroids. However, the improvement was short-lived. The patient is now essentially bed bound, requires a Hoyer lift for bed transfers, has fallen on several occasions and is completely bowel incontinent. Surgical intervention, chemotherapy and radiation therapy are no longer viable options. His condition is terminal due to an aggressive brain tumor.  Hospice care has been initiated.   

The patient's need for PCW 7 days per week, 24 hours per day, continuous care by more than 1 person, when mutual spouse is out of the community, and 7 days per week, 20 hours per day, continuous care by more than 1 person, when mutual spouse is in the community has clearly been established: given his progressive functional decline and the gravity of his prognosis. Based on the documents reviewed, the requested PCW 7 days per week, 24 hours per day, continuous care by more than 1 person, when mutual spouse is out of the community, and 7 days per week, 20 hours per day, continuous care by more than 1 person, when mutual spouse is in the community are appropriate to meet the patient's rapidly declining functional capacity.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Worker (PCW) 7 days per week, 24 hours per day, continuous care by more than 1 person, when mutual spouse is out of the community, and 7 days per week, 20 hours per day, continuous care by more than 1 person, when mutual spouse is in the community is substantiated.