Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal care worker (PCW) 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week. 

The insurer denied coverage for personal care worker (PCW) 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week. 

The denial is modified. 

According to the documentation submitted, this is the case of a patient with a history of osteoarthritis, osteoporosis, dementia, coronary artery disease, congestive heart failure (CHF), and hypertension. According to the Uniform NYS Comprehensive Health Assessment (UAS), the patient lives alone. The patient is totally dependent for meal preparation, shopping and housekeeping. The patient requires assistance for bathing, dressing and locomotion, walks without an assistive device and needs maximal assistance for weight bearing. The patient and their doctor have requested 24 hours per day 7 days per week split shift for 168 hours total per week of personal assistance service (PAS). The insurer approved a reduction from the request to 70 hours per week leading to the external review. 
 
The insurer has denied approval for 168 hours per week of personal assistance services. In their denial letter, they write 70 hours per week should be sufficient to manage the patient's medical needs. The 70 hours per week approved may be used flexibly to help meet the patient's needs and maintain the patient's health and safety in the community. 
 
The patient is appealing. The patient needs maximal assistance with activities of daily living such as toileting, dressing, and bathing.  The patient also needs maximal assistance with weight bearing for walking. The patient and their physician believe the patient needs 168 hours a week to prevent further deterioration and maintain this level of care for safety reasons. 

This is an adult with chronic medical problems including osteoarthritis, osteoporosis, dementia, coronary artery disease, CHF and hypertension.   The patient lives alone.  The patient needs maximal assistance with weight bearing for walking and toileting.  The patient is incontinent of urine increasing the risk for falls.  The patient's physician indicates the patient is at high risk for falls due to dementia and balance problems and needs frequent feedings to prevent hypoglycemia. 
 
The NYS Comprehensive Assessment form was reviewed. There are inconsistencies with the above noted mental status in that the patient experiences forgetfulness. The patient is assessed as requiring maximal assistance for all of their Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL) tasks including meal preparation, ordinary housework and shopping, dressing, bathing and needs maximal assistance for weight bearing.  The hours approved assist the patient with the tasks listed above and for getting the patient ready for intermittent doctor's appointments. 

PAS hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance. 
 
The carrier's decision to approve the patient's 70 PAS hours should be modified with the weekly PAS hours increased to 84. The health care plan did not act reasonably in part. Based on the enclosed documents reviewed, the patient's needs can be appropriately provided and maintained with 84 PAS hours/week. The patient has the means for emergency assistance but needs help with phone use. This also increases her risk.  The patient also has the option of restructuring and flexibly using the all the PAS hours weekly to better maintain and meet the patient's functional needs. 

Based on the above, the insurer's denial is modified. The medical necessity for personal care worker (PCW) 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week is not substantiated. Personal care worker (PCW) 7 days per week 84 hours per week is medically necessary.