Diagnosis: Lung cancer
Treatment: Increase in Personal Care Worker (PCW) services to 7 days/week, 8 hours/day: 56 hours/week
The insurer denied coverage for an increase in PCW services to 7 days/week, 8 hours/day: 56 hours/week
The denial is upheld

This is a patient who has lung cancer that is metastatic to the brain. He lives with his daughter and ex-wife in a private home. He is currently approved for Personal Care Worker (PCW) services 5 hours/day, 7 days/week for a total of 35 hours/week. He is requesting via his treating physician an increase in PCW services to 7 days/week, 8 hours/day; 56 hours/week, which is currently under review.

The Uniform Assessment System (UAS) report was reviewed. The patient requires extensive assistance for bathing and dressing. Limited assistance is needed for personal hygiene, ambulation, toilet transfer/use and bed mobility. Limited assistance is also needed for eating and drinking. The patient is infrequently incontinent of bladder and continent of bowel. He remains capable of using his personal emergency response system (PERS). His cognition has modestly declined from "modified independent" to "minimally impaired." Otherwise there has not been a significant functional decline compared to the prior assessment. Based on the clinical records reviewed, this physician agrees with the insurer. The patient's health and safety can be appropriately provided and maintained by the currently approved Personal Care Worker (PCW) services 5 hours/day, 7 days/week for a total of 35 hours/week.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested increase personal care worker (PCW) services 7 days per week, 8 hours per day; 56 hours per week is not medically necessary.

The insurer's denial of coverage for personal care worker (PCW) services 7 days per week, 8 hours per day; 56 hours per week is upheld. Medical Necessity is not substantiated.