Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD(chronic obstructive pulmonary disease).
Treatment: Increase in personal care aide hours to 7 days a week, 2-12 hours a day (split shift)- 168 hours per week.
The insurer denied increase in personal care aide hours to 7 days a week, 2-12 hours a day (split shift)- 168 hours per week.
The determination is upheld.


This is a male patient with a past medical history of oxygen dependent, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, benign prostatic hyperplasia (BPH), vascular dementia, severe obstructive sleep apnea (OSA), anxiety, depression, congestive heart failure, diabetes mellitus type 2, osteoarthritis, chronic renal failure, degenerative spine disease, hyperlipidemia, constipation, varicose veins with edema, urinary incontinence, bowel incontinence, obesity, and thoracic aneurysm without rupture who had been assigned personal care assistant (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week based on an assessment performed via video.
The patient was in the emergency department (ED) with bleeding from a wound. The patient's pain provider sent a letter stating the patient had severe lower back pain radiating into both legs, bilateral knee pain, and weakness in both legs with instability. The provider noted the patient's condition had recently worsened and the patient was unable to perform activities of daily living. Lastly, the provider stated to improve the patient's quality of living and reduce his risk of falls, it was their professional opinion that the patient needs and would greatly benefit from around the clock assistance of home attendant. There was a request to increase PCA services and the patient underwent another video assessment. Notes from the assessment stated the patient lived with his spouse, had a decline in activities of daily living (ADL) status over the last 90 days, and had a deterioration in overall self sufficiency in the last 90 days.
The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's medical diagnoses and the patient's condition had significantly deteriorated recently following a coronavirus 2019 (COVID 19) infection complicated by respiratory failure, cardiac arrest, intubation, tracheostomy, and percutaneous endoscopic gastrostomy (PEG) tube placement. In addition, the primary care physician (or provider) (PCP's) letter stated the patient had recent spinal surgery with subsequent generalized muscle weakness and the patient was wheelchair-bound and the patient needed assistance with all ADLs. The provider also stated the patient required supervision around-the-clock day and night in order to provide a safe and clean environment, optimal nutrition, and prevent falls and injuries. Lastly, the provider stated they strongly believed the patient would benefit from a 24-hour / 7 days split shift of home care services.
The patient's psychiatrist provided a letter stating the patient's diagnosis of vascular dementia with depressed mood and the patient was in need of in-home aide services 12 x 12 hours. The patient's pulmonologist provided a letter stating the patient's medical diagnoses and symptoms of severe shortness of breath on exertion. The provider stated it was strongly recommended to increase the patient's home health aide hours. The patient's cardiologist provided a letter stating it was  their opinion that the patient receive at least 24 hours of home health aide services daily to complete the patient's routine daily tasks and the patient should not be unattended especially when walking.
The insurer sent a final adverse determination denial notice partially denying the request to increase PCA services, approving services 24 hours/day, 7 days/week, live in. The patient's son provided a letter appealing the denial decision stating the patient had sleep apnea and could not be left alone for 5 hours, the patient has had multiple falls and injuries that needed hospitalization from falling at home during the night, and the patient's wife is unable to help the patient. At issue is the medical necessity of an increase in personal care aide hours to 7 days a week, 2-12 hours a day (split shift)- 168 hours per week.

The services are not medically necessary. There is documentation of minimal change in assistance needs when comparing the assessments. There is no documentation from the patient's medical providers of the need for turning and repositioning every 2 hours. There is no documentation of overnight care logs that specifically document assistance needs with ADLs in the overnight hours. Although the patient's son reports the patient cannot be left alone due to his sleep apnea the patient's medical providers have not documented continuous assistance needs related to the patient's sleep apnea. There is no documentation of overnight care needs that would not allow a PCA 5 hours of uninterrupted sleep.