Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, diabetes, peripheral neuropathy, unsteady gait, morbid obesity, venous insufficiency, and heart failure. 
Treatment: Increase Personal Care Worker (PCW) Service To 7 Days A Week, 24 Hours Per Day Live-in Total of 91 Hours Per Week. 

The insurer denied the Increase Personal Care Worker (PCW) Service To 7 Days A Week, 24 Hours Per Day Live-in Total of 91 Hours Per Week. 

The denial is upheld. 

The patient is a male. His conditions include dementia, diabetes, peripheral neuropathy, unsteady gait, morbid obesity, venous insufficiency, and heart failure. Denial of in increase personal care worker (PCW) service to 7 days a week, 24 hours per day, live-in, total of 91 hours per week, is being appealed. The Plan approved PCW (personal care worker) services to 7 days per week, 3 hours per day for a total of 21 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: maximal assistance with meal preparation, housework, managing finances, phone use, and shopping; extensive assistance with managing medications, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, toileting, and eating; and supervision with bed mobility. He has occasional bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a deterioration in cognition but no significant change in physical functioning. 

An appeal letter notes the patient has multiple chronic conditions. Notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the previous UAS (Uniform Assessment System) evaluation. States the patient cannot manage scheduled and unscheduled activities that require him to transfer and ambulate. He has had 5 falls. His wife is unable to provide support. 

An appeal letter notes the patient requires assistance with all ADLs (activities of daily living), especially transfers and ambulation. He needs day and nighttime assistance. 

No, the increase in personal care worker services to 91 hours/week, live-in, is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase PCW (personal care worker) service to 7 days a week, 24 hours per day, live-in, total of 91 hours per week, is being appealed. The Plan approved PCW (personal care worker) services to 7 days per week, 3 hours per day for a total of 21 hours per week. 

This patient has multiple chronic medical conditions, including dementia and unsteady gait. UAS (Uniform Assessment System) evaluation completed shows the patient requires limited assistance with personal hygiene, upper body dressing, walking, locomotion, toileting, and eating. He does not require assistance with bed mobility. He requires extensive to maximal assistance with other ADLs (activities of daily living). He has occasional bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been no significant deterioration in physical functioning. Appeal statements note the patient needs assistance with scheduled and unscheduled day and nighttime ADLs (activities of daily living) due to needs for assistance with transfers and ambulation. The review shows that the patient's cognitive status has deteriorated with no significant deterioration in physical functioning. This information does not support the requested PCW (personal care worker) live-in services. The patient does not require a frequency care of a live-in aide. The assistance needed can be achieved with the current hours. PCW (personal care worker) services are not indicated when not tasks are being performed.  The approved PCW (personal care worker) 21 hours per week is appropriate and medically necessary to meets the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in PCW (personal care worker) to 7 days a week, 24 hours per day, live-in, total of 91 hours per week is not medically necessary. 

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