Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure
Treatment: increase in personal care worker (PCW) service 7 days per week, 8 hrs per day; 56 hours (hrs) per week. 
The insurer denied increase in personal care worker (PCW) service 7 days per week, 8 hrs per day; 56 hours (hrs) per week. 
The determination is overturned.

This is a female patient with a history of breast cancer, cervical cancer, atrial fibrillation, and heart failure. She lives alone. The patient has durable medical equipment at home of a rollator, straight cane, raised toilet seat with rail, shower chair, incontinence pads, and a commode. The patient was previously approved for Personal Care Worker (PCW) services 4 hours per day, 7 days per week (28 hours per week). The patient and her care team requested PCW service 7 days per week, 8 hours per day (56 hours per week). The health plan partially denied this request and approved 4.5 hours per day, 7 days per week (31 hours per week) of PCW services. The patient's granddaughter appealed this denial.
An in-person Uniform Assessment System (UAS) was completed. The patient was assessed at maximal assistance for tasks of meal preparation, ordinary housework, and shopping; extensive assistance for tasks of managing finances, stairs, transportation, equipment management, bathing, dressing upper body, and dressing lower body; limited assistance for tasks of managing medications, phone use, personal hygiene, walking, locomotion, transfer toilet, toilet use, and eating; and independent with task of bed mobility.
Another in-person UAS was completed. The patient was assessed at total dependence for the task of ordinary housework; maximal assistance for tasks of meal preparation and shopping; extensive assistance for the tasks of managing finances, managing medications, stairs, transportation, equipment management, bathing, dressing upper body, dressing lower body, transfer toilet, and toilet use; and limited assistance for the tasks of phone use, personal hygiene, walking, locomotion, bed mobility, and eating. A tasking tool was used to determine that she requires 25.4 hours of aide service per week.
The patient's primary care physician (PCP) states that she needs assistance with all activities of daily living, including feeding, dressing, transferring, toileting, and ambulating. At issue is the medical necessity of increase in personal care worker (PCW) service 7 days per week, 8 hrs per day; 56 hours (hrs) per week. 

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, Personal Care Worker (PCW) service 7 days per week, 8 hours per day (56 hours per week) is medically necessary.
There is documentation in the second UAS of the patient requiring extensive assistance with tasks of transfer toilet and toilet use and limited assistance with tasks of walking and locomotion. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan did not document a plan to meet these unscheduled and unpredictable care needs. The Plan should not have utilized a tasking tool to calculate hours given that the patient has unscheduled and unpredictable care needs. There is documentation from the patient's PCP of the medical necessity of increased PCW services.
The patient lives alone and does not have informal support for the entire time outside of the previously assigned PCW hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCW services is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).