Diagnosis: Cognitive and physical impairment.

Treatment: Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week.

The insurer denied coverage for PCW Services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week.

The denial is overturned.

This is a female patient with a past medical history of coronary artery disease, hypertension, congestive heart failure, type 2 diabetes mellitus, coronavirus disease 2019 (COVID-19) associated pneumonia, urinary tract infections, pressure ulcers, anemia, constipation, insomnia, incontinence, vertigo, osteoarthritis, impaired balance, as well as a history of falls. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter, her Personal Care Worker and a nurse providing wound care, were present on the call. The patient lives alone in a private home, and she is bed bound. Her activities of daily living status notes overall self-sufficiency decline.

The patient's needs are: Total dependence/Maximal assistance for all functions, Cognition: There is severe impairment, Continence: There is frequent urinary and bowel incontinence, Wound: Stage III right buttock skin breakdown.

An increase to personal care worker (PCW) services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week is being requested.

The patient is dependent for all activities of daily living (ADLS). Comparison of Uniform Assessment System (UAS) reports shows that she has deteriorated. She has severe dementia and bowel and bladder incontinence. She has a history of pressure sores and currently has a stage III sore. Activity Log does not note turning and positioning, but this should be done. Incontinence needs to be promptly handled, either with assistance to the bathroom if possible or clean-up of her and bed thereafter. The provision of diapers and alternate pressure beds is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" changing diapers regularly and positioning are also necessary. Given her degree of cognitive and physical impairment and presence of sores with incontinence, the plan's determination is overturned.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week is overturned. Medical necessity is substantiated.