Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain, osteoarthritis
Treatment: Personal Care Aide (60 hours (hrs) per week)
The insurer denied Personal Care Aide (60 hours (hrs) per week). 
The determination is overturned.

The patient is a female with a past medical history of hypertension, osteoarthritis, anxiety, hyperlipidemia, osteoporosis, chronic obstructive pulmonary disease (COPD), asthma, insomnia, cervical radiculopathy, memory loss, depression, gastroesophageal reflux disease (GERD), and low back pain who requested personal care assistant (PCA) services 60 hours per week (hours/week).
The patient underwent a video assessment assessing the patient at total assistance with the task of managing finances while maximum assistance with tasks of meal preparation, ordinary housework, managing medication, and shopping. With the tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, and transfer toilet the patient was assessed at extensive assistance while independent with the tasks of phone use, walking, locomotion, toilet use, bed mobility, and eating. Tasking tool estimated 20.1 hours/week.
The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's medical diagnoses, and the patient needed help with daily activities and assistance to and from medical appointments and required more hours for personal care and home health aide services. The insurer sent a final adverse determination denial notice denying the request stating no updated medical records had been submitted by the patient's doctor showing that the patient needed additional care due to a worsening of either the patient's existing illnesses or new medical issues that had come up since her last assessment. The denial also stated there was no documentation from the patient's doctor stating why the patient's care needs could not be completed within the current aide hours and the need for safety and supervision monitoring as a stand-alone task does not meet criteria for an increase in aide hours. The insurer sent an approval notice approving PCA services 21 hours/week. At issue is the medical necessity of Personal Care Aide (60 hours (hrs) per week). 
The services are medically necessary. There is documentation from the patient's medical provider of medical necessity of PCA services. There is documentation from the plan's assessment that the patient requires extensive assistance with transfer toilet. The patient therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs when the patient does not have formal support. There is documentation that the patient's daughter works and has to care for her own child with medical condition and therefore is not available at all times outside of the currently assigned PCA services of 21 hours/week. The plan assumed the patient had informal support outside of all of these hours and this is not the case. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs).