Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, Alzheimer's, peripheral vascular disease, cardiomyopathy, and prostate cancer
Treatment: Increase Personal Care Worker (PCW) To 7 Days Per Week, 24 Hours Per Day, Continuous Care by More than One Person: for 168 Hours Per Week
The insurer denied: Increase Personal Care Worker (PCW) To 7 Days Per Week, 24 Hours Per Day, Continuous Care by More than One Person: for 168 Hours Per Week
The denial is partially overturned.

The patient is an elderly male. His conditions include diabetes, Alzheimer's, peripheral vascular disease, cardiomyopathy, and prostate cancer. Denial of increase personal care worker (PCW) to 7 days per week, 24 hours per day, continuous care by more than one person: for 168 hours per week, is being appealed. The health plan approved PCW (personal care worker) 7 days per week for 49 hours per week.

Uniform Assessment System evaluation performed 6 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistant with managing medications, phone use, bathing, and lower body dressing; extensive assistance with personal hygiene, upper body dressing, and toilet use; and limited assistance with walking, locomotion, toilet transfer, bed mobility, and eating. Clinical notes provided indicate the patient is totally dependent for IADL (instrumental activities of daily living) and dependent with ADL (activities of daily living). He may require supervision. He has impaired judgment and may pull out suprapubic tube.

Appeal statements indicate the patient has cognitive disturbance and dementia. He is totally dependent and has a moderate risk of fall. He needs full-time supervision. 

The requested Increase Personal Care Worker (PCW) To 7 Days Per Week, 24 Hours Per Day, Continuous Care by More than One Person: for 168 Hours Per Week is medically necessary, in part.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase personal care worker (PCW) to 7 days per week, 24 hours per day, continuous care by more than one person: for 168 hours per week, is being appealed. The health plan approved PCW (personal care worker) 7 days per week for 49 hours per week. This patient has multiple chronic medical conditions. Uniform Assessment System evaluation performed 6 months ago shows he needs assistance with all ADLs (activities of daily living). He has a suprapubic catheter. Clinical notes and appeal statements indicate the patient has cognitive impairment and needs full time supervision. The information provided supports that the patient has significant impairments in his functional status that cannot be met with the approved PCW (personal care worker) 49 hours per week. However, the information does not support that the patient has continuous needs. PCW (personal care worker) services are not indicated for supervision or when no tasks are being performed. The requested increase in PCW (personal care worker) to 7 days per week, 24 hours per day, continuous care by more than one person: for 168 hours per week, is not appropriate. Rather, an increase to PCW (personal care worker) 7 days per week, live-in for one person: for 91 hours per week, is medically necessary.