Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary incontinence
Treatment: Personal Care Worker (PCW) service from 7 days/week, 8 hours/day, 56 hours/week to 7 days/week, 24 hours/day (live-in), 91 hours/week
The insurer denied PCW service from 7 days/week, 8 hours/day, 56 hours/week to 7 days/week, 24 hours/day (live-in), 91 hours/week. 
The determination is overturned.

The patient is a male with a past medical history of urinary incontinence, hypertension, chronic prostatitis, insomnia, anemia, anxiety, gastroesophageal reflux disease (GERD), vascular dementia, macular degeneration with legal blindness, restless leg syndrome, vitamin B12 deficiency, constipation, and osteoarthritis who had been assigned personal care assistant (PCA) services 8 hours/day, 7 days/week, to total 56 hours/week.

There was a request to increase PCA services and the patient underwent another assessment. Notes from the assessment stated the patient lived alone in a 1-bedroom apartment and had a decline in activities of daily living (ADLs) status and deterioration of overall self-sufficiency in the last 90 days.

The insurer sent a final adverse determination denial notice continuing to partially deny request to increase PCA services stating the patient was using durable medical equipment (DME) and the patient would benefit from a bedside urinary drainage bag with a larger volume capacity. The patient had an office visit with the primary care physician (or provider) (PCP) with office note stating the patient had sudden mild to moderate and rapidly increased weakness the day before and almost passed out while sitting in a chair and the patient was requesting an increase in PCA services.

The patient's PCP provided a letter stating the patient had significant vision impairment, prominent generalized weakness, somnolence at daytime episodes, vascular dementia, hypertension, low back pain, ataxic gait, and was using a urinary bag on an everyday basis due to continued urinary leakage. The letter also stated the patient had significant deterioration physically and mentally.

The patient's son provided a letter noting the patient lived alone and when his aide left for the day, the patient could not function without supervision, support, and around-the-clock care. At issue is the medical necessity of Personal Care Worker (PCW) service from 7 days/week, 8 hours/day, 56 hours/week to 7 days/week, 24 hours/day (live-in), 91 hours/week.

The services are medically necessary. There is documentation from the patient's PCP of medical necessity of increased PCA services. There is documentation from the patient's family that they are unable to provide informal support outside of the currently assigned PCA service hours. The plan's own assessment documented the patient has at least limited assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore the patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the insurer indicated. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, 7 days/week, to total 91 hours/week are medically necessary for this patient.