Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post fall and repair of a left femur fracture.

Treatment: Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day continuous split shift by more than 1 person, at 168 hours per week.

The insurer denied coverage for PCW Services of 7 days per week, 24 hours per day continuous split shift by more than 1 person, at 168 hours per week. 

The denial is upheld. 

This is a female patient with a past medical history of cancer, depression, hearing loss, hypertension, hyperlipidemia, muscle weakness, malignant neoplasm of the ovary, malignant neoplasm of the skin, general osteoarthritis, and insomnia. The patient was admitted to Sub Acute Rehab (SAR) status post (s/p) a fall and repair of a left femur fracture. The plan is to discharge the patient home with extensive assistance with her activities of daily living. Based on a telephonic New York State Department of Health's Uniform Assessment System (UAS-NY) done prior to the patient's admission to the SAR, the patient lives alone; her daughter was present on the call. The patient is said to need extensive assistance with meal preparation and ordinary housework. She needs limited assistance with managing finances, managing stairs, shopping, transportation, equipment management, bathing, dressing her lower body and eating. The patient needs supervision with managing medications. She is independent with personal hygiene, dressing her upper body, toilet transfer, toilet use, bed mobility, walking and locomotion. The patient uses an assistive device for locomotion indoors. She is infrequently bladder and bowel incontinent. The patient experiences mild, intermittent pain that is adequately controlled by therapeutics. No hospitalizations or falls within the last 90 days were noted. No pressure ulcers were noted either. An increase to personal care worker (PCW) services of 7 days per week, 24 hours per day continuous split shift by more than 1 person, at 168 hours per week is being requested.

The patient when assessed in the UAS needed limited assistance with activities of daily living. In the intervening time she had a fall with left femoral fracture. She required Rehab. She developed a decubitus ulcer that healed. Review of the therapist's assessment reveals that the patient is independent in bed mobility and needs supervision for transfers. She ambulates 120 feet with a walker with supervision and navigates 8 steps with assistance.      

At issue is the medical necessity of PCW services of 7 days per week, 24 hours per day continuous split shift by more than 1 person, at 168 hours per week.

The available documentation does not support the need for 24 hour services. The patient has improved greatly since the fall and has a level of function as noted above that does not support the need for 24-hour services. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day continuous split shift by more than 1 person, at 168 hours per week is upheld.  Medical necessity is not substantiated.