Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, arthritis, spinal stenosis

Treatment: PCW (Personal Care Worker) services 7 days per week, 24 hours per day, live-in, 91 hours total.

The insurer denied coverage for PCW services 7 days per week, 24 hours per day, live-in, 91 hours total.

The denial is modified.

This is a geriatric patient with medical problems that include stroke, arthritis and spinal stenosis.  The patient lives with spouse who receives Personal Care Worker services 7 days per week, 3 hours per day. The insurer approved PCW services 5 hours per day, 7 days per week, totaling 35 hours per week. The request is for PCW services 7 days per week, 24 hours per day, live-in, 91 hours total. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. Maximal to extensive assistance is needed for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient requires extensive assistance for bathing, dressing, eating and toilet use. Limited assistance is needed for personal hygiene, bed mobility, locomotion, ambulation and toilet transfer. The patient is frequently incontinent of bladder and bowel. The patient's medical conditions, functional ability and mobility are not at the level as to require the requested PCW services 24 hours per day, 7 days per week (live-in). However, the functional impairments support an increase of PCW services to 10 hours per day, 7 days per week (total of 70 hours per week). This physician would agree the patient may require additional monitoring. However, safety monitoring under PCW services does not include monitoring an individual (with cognitive impairment) when no other Level I or Level II personal care service tasks are being provided. Based on the records reviewed, the patient's health and safety would be more appropriately provided and maintained by increasing PCW services to 10 hours per day, 7 days per week; totaling 70 hours per week.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, increasing PCW services from 7 days per week, 5 hours per day; 35 hours per week, to 7 days per week, 24 hours per day; live-in; 91 hours per week is not medically necessary. Increasing PCW services to 10 hours per day, 7 days per week; 70 hours per week is medically necessary.  

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an increase in personal care worker (PCW) services from 7 days per week, 5 hours per day; 35 hours per week, to 7 days per week, 24 hours per day; live-in; 91 hours per week is not substantiated. However, increasing PCW services to 10 hours per day, 7 days per week; 70 hours per week is medically necessary.