Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence.
Treatment: Personal care worker.
The insurer denied Personal care worker service 7 days per week, 11 hours per day. 
The health plan's determination is overturned. 

The patient is a male with past medical history of benign prostatic hyperplasia (BPH), hypertension, urinary incontinence, congestive heart failure, hemiplegia/hemiparesis status post cerebrovascular accident (CVA) with left-sided weakness, osteoarthritis, and hyperlipidemia who had been assigned PCW (personal care worker) services 6 hours/day, 7 days/week, to total 42 hours/week. The patient had a hospitalization with COVID-19 and there was a request to increase PCW services. The patient underwent a telephonic assessment tool  assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and transportation while maximum assistance with tasks of managing finances, managing medication, stairs, shopping, equipment management, bathing, dressing lower body, and toilet use. The patient was assessed at extensive assistance with tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet while limited assistance with tasks of bed mobility and eating. Notes from the assessment noted the patient was unable to express goals due to cognitive impairment, had Mini-Mental State Examination (MMSE) of 4 out of 30, activities of daily living (ADL) status had declined, and overall self-sufficiency had deteriorated.

Personal care worker service 7 days per week, 11 hours per day is medically necessary for this patient.
There is documentation provided that the patient had decline in cognitive and functional status following hospitalization for COVID-19 infection. The patient's daughter was no longer able to provide informal support. The patient requires at least limited assistance with all activities of daily living (ADL) / Instrumental activities of daily living (IADL). He specifically requires extensive assistance with walking, locomotion, and transfer toilet and maximum assistance with toilet use. Therefore, the patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's ADL/IADL needs cannot be met with current hours and/or adaptive equipment and/or medical supplies. The requested increase in PCW services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The universal assessment tool documented the patient was unable to express goals due to cognitive impairment, was moderately impaired cognitively, had decline in ADL status and had deterioration in overall self-sufficiency as well as a very low Mini-Mental State Examination (MMSE) at 4 out of 30. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCW services 11 hours/day, 7 days/week, to total 77 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.