Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal care aide (PCA) services: 5.5 hours per day- 6 days a week- for the total amount of 33 hours per week.
The insurer denied personal care aide (PCA) services: 5.5 hours per day- 6 days a week- for the total amount of 33 hours per week.
The determination is overturned.

This is a female patient with a past medical history of osteoarthritis, hyperlipidemia, hypertension, osteoporosis, dementia, and vitamin D deficiency who had been assigned personal care aide (PCA) services 3.5 hours/day, 7 days/week, to total 24.5 hours/week. There was a request to increase PCA services and the patient underwent a video assessment. The tasking tool estimated 24.5 hours of assistance per week. Notes from the assessment stated the patient lived with her daughter and had moderate intermittent pain from osteoarthritis.
The insurer sent an initial adverse determination denial notice denying the request to increase PCA services stating the request was not medically necessary. The patient's primary care physician (or provider) (PCP) sent a letter stating the patient's medical diagnoses including symptoms of dizziness upon standing and walking with an unstable gait. The letter also noted the patient was in need of assistance with daily activities of daily living (ADLs) and safety at home along with daily reminders of administration of her medication and daily meal preparation as the patient had been losing weight. The provider noted these conditions also caused the patient to be high risk of a fall while ambulating around with her cane or Rollator walker and it was their medical opinion the patient should have at least 12 hours/day of home health aide assistance and it was medically necessary. The insurer sent a final adverse determination denial notice continuing to deny the request to increase PCA services stating the patient lived with her daughter who was supportive and involved in her care and granting additional hours was not provided when tasks were not being performed. The patient appealed denial decision. At issue is the medical necessity of personal care aide (PCA) services: 5.5 hours per day- 6 days a week- for the total amount of 33 hours per week.
The services are medically necessary. There is documentation from the patient's primary care physician (or provider) (PCP) of the medical necessity for increased PCA services to 12 hours/day. The patient's PCP documents that the patient has lost weight due to an inability to prepare and reheat her own meals. The patient requires at least limited assistance with walking and locomotion and therefore has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs when the patient does not have informal help. The tasking tool underestimated the hours per week the patient would need to safely complete ADLs and instrumental activities of daily living (IADLs). The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 5.5 hours per day- 6 days a week- for the total amount of 33 hours per week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.