Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied increase in PCW hours to 7 days per week 12 hours per day 84 hours per week Level I services. 
The denial is overturned in whole.

The patient is a female with past medical history of iron deficiency anemia, diabetes mellitus type 2, constipation, heart failure, gastroesophageal reflux disease (GERD), mild intermittent asthma, diabetic neuropathy, hyperlipidemia, hypertension, gout and sacral pressure ulcer who had personal care worker (PCW) service hours 4 hours/day, 5 days/week. There was a request to increase PCW service hours and patient had an assessment tool performed over the phone. The patient was interviewed by assessment nurse alone without family members. The nurse noted the patient ambulates with a straight cane, has no psychiatric issues, monitors blood sugars independently, is able to self-administer medications, including injectable insulin and had no hospitalization within the last 90 days. It noted the patient was in private home/apartment/rented room at the time of assessment. This assessment tool assessed the patient at maximum assistance for task of ordinary housework while extensive assistance with tasks of meal preparation, stairs, shopping and transportation. The patient was assessed at limited assistance with tasks of equipment management, bathing and dressing lower body while set up only for tasks of managing finances and phone use. She was assessed as independent with tasks of dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility and eating.

The insurer provided final adverse determination denial notice denying increase of PCW service hours to requested 12 hours/day, 7 days/week to total 84 hours/week but did increase current PCA service hours to 4 hours/day, 7 days/week to total 28 hours/week. The letter stated increase in service hours was denied because the patient did not meet the criteria, was able to walk 60 feet with help and assistive device (walker) and able to transfer and use toilet with assistance. The letter noted the plan is not required to include safety monitoring as a separate task or calculate any minutes allotted for safety monitoring as part of the total personal care service hours and the tasking tool performed indicated 3 hours per day of PCW service is sufficient to meet the patient's needs and complete tasks. The provider at SNF provided a letter stating the patient is able to make some of her needs known, is able to ambulate 50 feet with rolling walker and moderate assistance, has unsteadiness, is at high risk for falls and requires assistance to go to the bathroom. The provider notes the patient requires PCW service hours 12 hours/day, 7 days/week at all times for safety reasons.  The patient's family appealed insurer decision. The patient had psychiatric consult diagnosing the patient with dementia with depression and started Remeron 7.5 milligrams (mg) nightly.

Based on the patient's PT notes the patient is not independent with personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use and bed mobility and is at least is need of extensive assistance and in some tasks up to maximum assistance. The letter provided by the SNF provider indicates the patient requires 12 hours of PCW service hours, 7 days/week to total 84 hours/week. The patient does not have an informal helper outside of the PCW service hours. The patient has a stage 2 sacral decubitus ulcer which would require the patient to be turned and/or re-positioned every 2 hours if not ambulating. The patient has unscheduled needs which are not taken into account on the assessment tool. PCW service hours are not solely for the safety and supervision of the patient but to assist the patient with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). PCW services are medically necessary at 12 hours/day, 7 days/week to total 84 hours per week.