Diagnosis: Vertigo, Depression and Dementia.
Treatment: Personal Care Worker (PCW) services 7 days per week, 12 hours per day: 84 hours per week.

The insurer denied coverage for Personal Care Worker (PCW) services 7 days per week, 12 hours per day: 84 hours per week.

The denial is overturned.

This is an elderly patient with multiple medical problems including vertigo, depression and dementia. She was recently hospitalized, transferred to a nursing facility and discharged. The patient is approved for PCW services 7 hours/day, 7 days/week for a total of 49 hours/week and is requesting an increase to 7 days/week, 12 hours/day: 84 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." She requires extensive assistance for bathing, personal hygiene, dressing, ambulation and toilet transfer/use. Limited assistance is needed for bed mobility and eating. She is frequently bladder incontinent and infrequently bowel incontinent. There has been a functional decline compared to UAS report, particularly for locomotion, ambulation and toilet use. Her activities of daily living (ADL) status and overall self-sufficiency over the past 90 days have declined and deteriorated, respectively. The combination of the patient's cognition and functional decline support an increase in PCW. Her condition and functional needs are at a level and unpredictable as to require the requested 84 hours/week. Based on the enclosed documents reviewed, the patient's health and safety is more appropriately provided and maintained by increasing the PCW to 84 hours/week.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested Personal Care Worker (PCW) services 7 days/week, 12 hours/day; 84 hours/week is medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Personal Care Worker (PCW) services 7 days per week, 12 hours per day; 84 hours per week services is substantiated.