Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD
Treatment: Personal care services (PCS) 7 hours a day, 7 days a week, for a total of 49 hours.
The insurer denied the Personal care services (PCS) 7 hours a day, 7 days a week, for a total of 49 hours.
The determination is overturned.

The patient has a past medical history of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), glaucoma, diabetes mellitus (DM) Type 2, hypertension, anxiety, depression, osteoarthritis, benign prostatic hyperplasia (BPH), urinary incontinence, and coronary artery disease (CAD) who had been assigned personal care assistant (PCA) services 5 hours/day, 7 days/week, to total 35 hours/week based on a telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, shopping, and dressing lower body while extensive assistance with tasks of managing finances, managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating.

There was a request to increase PCA services and the patient underwent a telephonic assessment tool assessing the patient at total assistance with task of ordinary housework and maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, stairs, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use while limited assistance with phone use and bed mobility. The patient was assessed at independent with the task of eating.

The insurer sent initial adverse determination denial notice denying request to increase PCA hours. The patient's primary care physician (PCP) provided a letter stating the patient's medical diagnoses and the need of assistance with activities of daily living (ADLs) and that it was medically necessary to have his home care hours increased.

The insurer sent final adverse determination denial notice denying the request to increase PCA services stating a medical professional must not recommend a number of hours of services that an individual should be authorized to receive and that aides do not manage behaviors or medical conditions as this is outside of their scope of practice. The denial further stated the patient should follow-up with his doctor regarding his medical needs and personal care services for companion care or for safety supervision are not a covered service under his plan benefit. Lastly, the denial stated the aide cannot prevent the patient from falling or getting injured, the patient should consider physical therapy, and the patient should utilize adaptive equipment to better meet his needs.

The patient's PCP provider sent a letter noting that the patient was homebound, had to be seen during a housecall and required home care throughout the day and night. The PCP letter also stated the patient required extensive assistance with activities of daily living including toileting, assistance with transfers, ambulation, meal preparation, and bathing. An office note provided states the patient contracted coronovirus 2019 (COVID-19) and required oxygen therapy. The patient appealed the denial decision to increase PCA services.

At issue is the medical necessity of personal care services (pcs) 7 hours a day, 7 days a week, for a total of 49 hours. 

There is documentation from the patient's PCP that the patient has had a functional decline requiring increased PCA services and in his last letter the PCP recommended around-the-clock PCA services. Since the patient's assessment, he has had COVID-19 requiring oxygen. The patient has assistance needs with all tasks except for eating. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with medical supplies and adaptive equipment. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ instrumental activities of daily living (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 7 hours/day, 7 days/week, to total 49 hours/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 his own home.