Diagnosis: Traumatic brain injury
Treatment: Increase PCW services from seven days per week, 12 hours per day to seven days per week, 24 hours continuous care by more than one person

The proposed treatment of an increase in PCW services to seven days per week, 24 hours continuous care by more than one person is deemed medically necessary.

The patient is a male with a history of traumatic brain injury (TBI). He is chronically wheelchair/bedbound and dependent on maximum assistance for all of his activities of daily living (ADLs).

Appeal review requested for potential approval of an Increase in personal care worker (PCW) services from seven days per week, 12 hours per day to seven days per week, 24 hours continuous care by more than one person for improved assistance with completion of the patient's ADLs.

This is a male with a history of traumatic brain injury (TBI). He is chronically wheelchair/bedbound and dependent on maximum assistance for all of his activities of daily living (ADLs). Per recent documentation from the patient's attending physician, the patient needs to be repositioned frequently throughout the nighttime to prevent the development of bedsores/pressure ulcers. Furthermore, the patient's spouse, his main caregiver at nighttime has been recently diagnosed with breast cancer and will require chemotherapy and radiation therapy which will render her with generalized weakness, fatigue and unable to provide care for her husband at nighttime. For these reasons, the currently approved plan of PCW services seven days per week, 12 hours per day is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in PCW services to seven days per week, 24 hours continuous care by more than one person is deemed medically necessary for improved assistance with completion of the patient's ADLs.