Diagnosis: Anxiety, cancer, CAD, depression, heart failure and dementia.
Treatment: Increase of Personal Care Worker services 7 days per week, 12 hours per day; 84 hours per week.
The insurer denied the increase of Personal Care Worker services 7 days per week, 12 hours per day; 84 hours per week.
The denial is upheld.

The patient is a female with conditions including anxiety, cancer, CAD (coronary artery disease), depression, heart failure and dementia. The patient is requesting an increase in PCW (personal care worker) services from 28 to 84 hours per week.

The patient's assessment showed the following: minimally impaired cognition; maximal assistance with meal prep and shopping; total dependence with housework; extensive assistance with managing finances and medications, phone use, stairs, transportation, bathing, and LB (lower body) dressing; limited assistance with personal hygiene, UB (upper body) dressing, locomotion, toileting, and bed mobility. The patient lives alone. The patient's son notes that the patient has a history of frequent falls due to weakness, but the patient declined PT (physical therapy).

No, the increase of Personal Care Worker services 7 days per week, 12 hours per day; 84 hours per week is not medically necessary.

Medically necessary services are typically the following:

1) Safe, 2) Effective, 3) Generally accepted national standard of medical practice, 4) Not provided primarily for convenience of the patient or the practitioner, and 5) The least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested increase of Personal Care Worker Services 7 days per week, 12 hours per day; 84 hours per week is not medically necessary, because it is not in accordance with generally accepted national standard of medical practice for this patient's scenario.

Personal Care Worker services provide hands-on assistance to individuals to include the following: assistance with ADLs (activities of daily living); health maintenance activities; and routine support services. This patient requires assistance as noted above. Assessment by PT for fall risk was declined. The patient requires limited assistance with ambulation, transfers and toileting. The assessment does not support the medical necessity for Personal Assistance service for a total of 84 hours per week. The approved 28 hours per week are sufficient to provide assistance with ADLs that include meal prep, housework, medications, shopping, transportation, and dressing.