Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Personal Care Aide, 7 Days x 24 Hours Live-In.
The insurer denied Personal Care Aide, 7 Days x 24 Hours Live-In. 
The determination is overturned.

The patient has a past medical history of rheumatoid arthritis, dementia, chronic obstructive pulmonary disease (COPD), anemia with a history of gastrointestinal (GI) bleeding, constipation, osteoporosis, osteoarthritis, hypertension, hypothyroid, and urinary incontinence, who had been assigned personal care assistant (PCA) services. The patient was hospitalized with weakness and a coronavirus disease 2019 (COVID-19) infection and was discharged to home. The patient was admitted again following a fall with injuries with subsequent transfer to rehabilitation and then discharged to home.
There was a request to increase PCA services, and the patient underwent a video assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With tasks of bed mobility and eating the patient was assessed at extensive assistance. The patient underwent another video assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with the tasks of managing medication, phone use, transportation, bathing, personal hygiene, dressing upper/lower body, and toilet use. With the tasks of stairs and transfer toilet the patient was assessed at extensive assistance, while limited assistance with tasks of walking, locomotion, and bed mobility. The patient was assessed at supervision with the task of eating. Notes from the assessment stated the patient lived alone, and her sons had been taking turns staying overnight to assist the patient.

The patient had a home visit by the primary care physician (or provider) (PCP) with the office note stating patient had difficulty ambulating and needed assistance and guidance and used a walker. The office note also stated the patient needed help with multiple activities of daily living (ADLs) and was unable to perform any Instrumental activities of daily living (IADLs) independently. The patient's PCP provided a letter stating the patient had been under their care for the last year and had been seen at home on a monthly basis due to homebound status. The letter noted the patient was unable to ambulate in her apartment due to her medical conditions and needed assistance transferring and supervision while walking. In addition, the provider's letter stated the patient was not able to hold the walker or utensils in her hands due to joint deformities. The letter also stated the patient needed assistance with bathing, toileting, and dressing, the patient was unable to warm a meal for herself, do any grocery shopping, or do any housekeeping tasks. The patient also suffered from episodes of orthostatic hypotension, which often resulted in falls when not supervised. The letter also stated with attempts to get up on her own at night, the patient had become dizzy and had falls. Lastly, the provider stated due to the decline in the patient's condition and risk for various complications such as falls and skin injury, medication error and more, as well as to optimize the patient's quality of life the provider requested an increase in her home health aide hours to provide an aide during the night. The patient's home health certification and plan of care was completed and signed.

At issue is the medical necessity of a Personal Care Aide: 7 Days x 24 Hours Live-In.

The services are medically necessary. There is documentation from the patient's medical provider of worsening functional and cognitive status. There is documentation from the patient's medical provider of medical necessity of increased PCA services in the overnight hours. The plan's own assessment noted the patient needed at least limited assistance with walking, locomotion, transfer toilet, and toilet use. The patient, therefore, 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 requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's assistance needs cannot be met solely with adaptive equipment and medical supplies. 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 24 hours/day, live-in, 7 days/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.