Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Personal Care Aide Services.

The insurer denied the Personal Care Aide Services.  The determination is overturned.

The patient has a past medical history of depression, dementia, lacunar infarct, hypertension, hyperlipidemia, diastolic congestive heart failure, benign prostatic hyperplasia (BPH), coronary artery disease, diabetes mellitus type 2, diabetic neuropathy, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea on continuous positive airway pressure (CPAP), osteoporosis, chronic low back pain, morbid obesity, urinary incontinence, unsteady gait, and generalized weakness.  He was assigned a personal care aide (PCA) services hours 8 hours/day, 7 days/week, to a total of 56 hours/week based on the assessment tool performed.  The patient was assessed at total assistance with tasks of meal preparation and ordinary housework, while assessed at maximum assistance with tasks of shopping and dressing the lower body.  He was evaluated at extensive assistance with tasks of managing finances, stairs, transportation, bathing, dressing the upper body, walking, locomotion, transfer toilet, and toilet use.  The patient was assessed at limited assistance for tasks of managing medication and personal hygiene, while independent with tasks of bed mobility and eating.  For the task of equipment management, the assessment noted the "activity did not occur."  There was a request to increase PCA service hour to 12 hours/day, 7 days/week, to total 84 hours/week.

The patient had another assessment tool performed, noting total assistance with the tasks of meal preparation and ordinary housework while maximum assistance with tasks of stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use.  The patient was assessed at extensive assistance for tasks of managing medication and dressing upper body, while assessed at limited assistance for tasks of equipment management, personal hygiene, and bed mobility.  He was assessed as independent with the task of eating.  The Registered Nurse (RN) assessor noted the patient felt anxious due to impaired mobility and a decline in health, is oxygen-dependent at 2 liters, fell two months ago, is taking Eliquis for anticoagulation, and Lasix for congestive heart failure.  The patient's primary care physician (PCP) provided a letter stating the patient's mental and physical condition has noticeably been deteriorating, and he needs constant help and support in his daily routines.  He needs help with dressing, meal preparation, personal hygiene, and is at high risk for falls.  The provider asked the plan to reevaluate this case and consider increasing his home care service hours, as failure to do so would resolve in a scenario of reduced safety for the patient.  The insurer provided a final adverse determination denial letter stating denial of the request to approve PCA service hours to 12 hours/day, 7 days/week to total 84 hours/week, and PCA hours would stay at 56 hours/week.  The denial noted there was no significant change in his condition to justify an increase in PCA service hours, and safety monitoring should not be authorized in the absence of activities of daily living (ADL) need.  At issue is the medical necessity of increased Personal Care Aide Level 2 Basic hours from 56 hours per week to 84 hours.

Yes, the requested increased Personal Care Aide hours are medically necessary.

The patient's PCP noted the patient's chronic medical conditions have worsened and deteriorated with an increased need for assistance with ADL and IADL tasks.  The tasking tool and subsequent allotment of PCA service hours do not take into account unscheduled needs such as transfer toilet, toilet use, and incontinence care.  The patient has continuous oxygen therapy and relies on a cane or leaning on a wheelchair for walking and locomotion and would need assistance with these tasks, as documented in the tasking tool.  The patient must walk/ambulate to the bathroom, making those tasks unscheduled, as well.  The increase in PCA service hours is not solely for safety and supervision but to provide assistance with stand-alone activities of daily living (ADL) and Instrumental Activities of daily living (IADL) tasks.  According to the assessment tool, the patient did have deterioration with an increase in assistance needs with tasks of managing medication, phone use, stairs, transportation, bathing, walking, locomotion, transfer toilet, toilet use, and bed mobility.  The patient does not have an informal helper outside of the provided PCA service hours.  Personal care services are medically necessary under Medicaid when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in his own home.  In addition, medical necessity is defined as medical care and services that are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interferes with such person capacity for a normal activity or threaten some significant handicap.  Therefore, an increase in PCA services hours to 12 hours/day, 7 days/week to a total of 84 hours/week, is medically necessary.