Diagnosis: Dementia.
Treatment: Personal Care Worker (PCW) services 7 days per week, 10 hours per day; 70 hours per week.

The insurer denied Personal Care Worker (PCW) services 7 days per week, 10 hours per day; 70 hours per week. The determination is overturned.

This is a female patient with a medical history notable for dementia, obesity, and gait dysfunction. The patient is approved for 7 hours per day, 7 days per week (49 hours per week) of personal care worker services. The patient and her care team requested an increase to 10 hours per day, 7 days per week (70 hours per week) and this request was denied by the health plan.

The patient's physician provided a letter of support for this appeal. The letter states that her chronic conditions result in her requiring assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). She also needs "frequent care management on a daily basis."

A letter of support for this appeal was provided by the patient's advocacy team. The letter states that she had a fall with a resulting shoulder fracture. Since that time, she has had difficulty with mobility and requires assistance when using the toilet, standing, and preparing food.

A Uniform Assessment System (UAS) was completed and was provided for review. The patient's cognition was minimally impaired and had shown a decline since previous assessment. A Mini-Mental State Examination (MMSE) score was 20/30 which is consistent with mild to moderate cognitive impairment. For her IADLs, she requires maximal assistance with meal preparation, housework, and shopping. She requires extensive assistance for finances and medications. For her ADLs, she requires maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for dressing upper body and toilet transfer. She requires limited assistance for hygiene, bed mobility, and eating. She was described as bed-bound. She is frequently incontinent of urine and continent of stool. A task tool associated with the assessment recommended 3.8 hours per day to address her personal care needs. At issue is the medical necessity of Personal Care Worker (PCW) services 7 days per week, 10 hours per day; 70 hours per week.

The requested health service of 7 days per week, 10 hours per day; 70 hours per week, personal care worker (PCW) is medically necessary for this patient.

The patient has had a functional decline following a fall. Her UAS now demonstrates that she requires maximal assistance with toileting and is incontinent of urine. Although her task tool only recommends 3.8 hours per day, her personal care needs can be expected to be of a continuous and unscheduled nature and thus, the task tool cannot adequately reflect her true level of need. In order to prevent additional falls, she will require more assistance with her ADLs and IADLs. She will also need prompt incontinence care to prevent skin breakdown and/or infection.