Diagnosis: Heart failure, COVID (Coronavirus disease)
Treatment: Personal Care Worker (PCW) services 12 hours/day 7 days/week
The insurer denied PCW services 12 hours/day 7 days/week.
The denial is upheld.

This elderly male patient has a history of hypertension, heart failure, thrombocythemia, and COVID (Coronavirus disease) pneumonia. He was hospitalized last year after being admitted with syncope due to hypoxia. The denial of personal care worker (PCW) services, 12 hours/day, 7 days/week, is being appealed. The health plan approved 8 hours/day, 7 days/week. Uniform Assessment System (UAS) evaluation performed 8 months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with lower body dressing; limited assistance with managing finances and medications, bathing, personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating.

A letter from the patient reports that he has prolonged effects after being infected with COVID. Lack of oxygen results in loss of consciousness. A letter from the provider notes the patient has chronic medical conditions. The patient suffers from syncope, shortness of breath, and unsteady gait. His condition is deteriorating due to unsteady gait. He has a history of multiple falls.

The proposed treatment is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs), health maintenance activities, and routine support services. This patient has multiple chronic conditions, including recent COVID pneumonia. The denial of PCW services 12 hours/day, 7 days/week, is being appealed. The health plan approved 8 hours/day, 7 days/week. UAS evaluation performed 8 months ago, shows the patient needs assistance with all ADLs except bed mobility and eating. Appeal statements indicate that the patient is oxygen dependent. He has syncope related to hypoxia. He has a history of falls due to an unsteady gait. The information provided does not support that the patient has functional needs that require an increase in PCW hours. PCW is not indicated for supervision or when no tasks are being performed. The approved PCW is appropriate to meet this patient's needs for assistance with ADLs. The proposed increase to services 12 hours/day, 7 days/week, is not medically necessary.