Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes. 

Treatment: Personal care worker (PCW) service 7 days per week, 12 hours per day; 84 hours per week. 

The insurer denied coverage for personal care worker (PCW) service 7 days per week, 12 hours per day; 84 hours per week. 

The denial is modified. 

This is a patient with chronic medical problems including hypertension, diabetes and chronic kidney disease. The patient is currently a resident at a nursing/long term care facility with no scheduled discharge date. The insurer approved personal care worker (PCW) 5.5 hours/day, 7 days/week (total 38.5 hours/week) and the request is for PCW 12 hours/day, 7 days/week (total 84 hours/week), leading to an external review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as moderately impaired. The patient reportedly requires maximal assistance to total dependence for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing and dressing. Limited assistance is reportedly needed for personal hygiene, eating, bed mobility, locomotion, toilet transfer/use and ambulation. During the assessment, the patient was "observed ambulating and transferring with walker and contact guard." The patient reports being frequently incontinent of bladder and infrequently incontinent of bowel. There have been 2 or more reported falls over the prior 30 days. The patient's cognitive and functional ability are much the same when compared to the previous UAS report. 

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested PCW 12 hours/day, 7 days/week (total 84 hours/week). The  letters dated from the patient's treating physicians describing the patient's clinical condition and recommending "12 hours a day for 7 days a week" were reviewed. The physicians do not provide the associated treatment notes to support their claim of the patient's reported functional incapacity. 

The therapy notes from the long term care facility also document a higher level of function when compared to the previous UAS reports. According to the occupational therapy progress note, the patient requires maximal assistance for bathing and toilet hygiene. Upper and lower body dressing required contact guard and maximal assistance, respectively.  Eating, drinking, hair grooming, oral and facial hygiene were documented as independent. According to the physical therapy notes, bed mobility required contact guard assistance. Transfers and ambulation (short distances with a rolling walker) were at the minimal assistance level. 

The reviewer would agree the patient may benefit from additional monitoring for safety; particularly upon initially returning home as well as the patient's reported weakness and falls risk. However, safety monitoring under PCW does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. The reviewer would also agree the patient's functional ability remains substantial.  Based on the submitted clinical records, the patient's health and safety are more appropriately provided and maintained at home by increasing PCW  to 9 hours per day - 7 days per week, for a total of 63 hours/week. The patient also has the option of restructuring and flexibly using the 63 PCW hours weekly (perhaps 2 shifts) to better maintain and meet their functional needs. 

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 personal care worker (PCW) service 7 days per week, 12 hours per day; 84 hours per week is not substantiated. However, increasing PCW to 9 hours per day, 7 days per week (total 63 hours per week) is medically necessary.