Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis, Decubitus Ulcers

Treatment: 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week of personal care worker services.

The insurer denied coverage for 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week of personal care worker services.

The denial is overturned.

 
The patient is seeking coverage for 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week of personal care worker services.  

The patient was evaluated by a registered nurse secondary to wounds.  The patient had a pressure ulcer on the right buttock that was stage IV and pressure ulcer on the left buttock that was stage III.  There was previous moisture associated skin damage on the posterior lateral chest and moisture associated dermatitis on the right side of the upper back that had healed.

A uniform assessment system assessment was conducted on the patient.  The patient lived on the second floor of a second story walk up family home.  The patient was unable to express goals of care due to cognitive decline.  The patient's cognitive skills were minimally impaired.  In specific recurring situations, decisions would become poor or unsafe.  The patient required cueing/supervision at those times.  The patient's short-term memory was impaired.  The patient was alert and oriented x2, forgetful, hard of hearing, and had slow vision.  The patient was often understood and would sometimes understand others.  There was difficulty finding words or finishing thoughts and prompting was usually required.  The patient responded adequately to simple, direct communication only.  The patient was totally dependent for meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing of the upper and lower body, toilet use, and bed mobility.  

This case involves a request to increase personal care worker services from 7 days/week, 24 hours/day, live-in, for 91 hours/week to 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week of personal care worker services.  The documentation detailed that the patient was totally dependent for most activities of daily living and instrumental activities of daily living.  The patient was bedbound and incontinent.  The patient has significant ulcers on the bilateral buttocks.  The patient's sister was unable to assist with the patient's care.  The treating provider noted that the patient needed to be repositioned frequently.  The provider recommended split shift 24-hour care.  The medical necessity of split shift care has been established for this patient.  The patient requires repositioning of such frequency that an in-living, 24-hour personal care aide would not be able to obtain 5 hours daily of uninterrupted sleep during an 8-hour sleep cycle.  Frequent repositioning is medically necessary based on the severity of skin breakdown and need for daily wound care management.  Additionally, the patient has significant functional deficits which require assistance.  Without the increase in personal care hours, the patient would be unable to continue to live at home.  As such, the denial of coverage for 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week of personal care worker services is overturned.

Based on the above, the insurer's denial must be reversed. 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 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week of PCW is substantiated.