Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week

The health plan denied Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.
The determination is Upheld.

The patient is a female with past medical history of osteoporosis, osteoarthritis, urinary incontinence, hypertension, congestive heart failure (CHF), spinal stenosis, deep vein thrombosis (DVT), chronic anticoagulation, anxiety, mild protein malnutrition, and bedbound status who had been assigned personal care aide (PCA) services 5 hours/day, 5 days/week to total 25 hours/week based on video assessment performed. Notes from the assessment stated the patient lived alone in a one-bedroom apartment, and the patient's daughter was supportive and involved in the patient's care. 
There was a request to increase PCA (Personal Care Aide) services, and the patient underwent another video assessment assessing the patient at total assistance with tasks of ordinary housework and managing finances with maximum assistance with tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, dressing her lower body, walking, locomotion, toilet transfer, and toilet use. The patient was assessed at extensive assistance with tasks of dressing her upper body and bed mobility with limited assistance with task of phone use and eating. Notes from the assessment noted the patient had been hospitalized and diagnosed with CHF (congestive heart failure) and a DVT (deep vein thrombosis). The patient was now on oxygen therapy and had a decline in overall self-sufficiency as well as activities of daily living since that time. The notes also stated the patient received significant weightbearing support to arms after toilet use and required weightbearing support to facilitate turning and positioning in bed. The patient's daughter lives out of state and is not available to assist. Since the patient's hospitalization, the patient has been on diuretic therapy and oxygen.
The insurer sent the initial adverse determination denial notice partially denying the request to increase PCA (Personal Care Aide) services with an increase to 6.5 hours/day, 7 days/week, to total 45.5 hours/week. The denial stated the patient required safety monitoring and supervision as a stand-alone task, and the patient's family was supportive and involved in her care.
Notes also stated the patient needed to be repositioned every 12 hours in order to prevent pressure ulcers, and the patient could not reposition herself.
An advocate for the patient sent a letter stating they had interacted and observed the patient in the past weeks and noted the client required significant assistance in moving from a lying position. The letter also stated toileting the patient required assistance in moving from the bed to the commode that was in the bedroom, and the patient had to use it several times at night due to diuretic medication.
The health plan's determination of medical necessity is upheld in whole.
The requested health service of PCA (Personal Care Aide) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - 168 hours per week is not medically necessary. Although there is documentation in the plan's own assessments that the patient requires assistance with unscheduled and unpredictable care needs, there is no documentation of care needs in the overnight hours that would not allow a PCA (Personal Care Aide) 5 hours of uninterrupted sleep. There is no documentation of the medical necessity of turning and repositioning every 2 hours. There is no documentation that the patient's home cannot accommodate a PCA (Personal Care Aide) overnight to sleep. 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.