Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
Treatment: Personal care aide (PCA) level 2: 12 hours per day- 6 days per week; consumer directed personal assistance program (CDPAP): 12 hours per day- 1 day per week- for a total of 72 hours necessary.
The insurer denied  personal care aide (PCA) level 2: 12 hours per day- 6 days per week; consumer directed personal assistance program (CDPAP): 12 hours per day- 1 day per week- for a total of 72 hours per week.
The determination is overturned.

The patient has a past medical history of osteoarthritis, urinary incontinence, chronic anticoagulation, hypothyroidism, chronic obstructive pulmonary disease (COPD), coronary artery disease, depression, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, and macular degeneration who had been assigned personal care assistant (PCA) services at 7 hours/day, 6 days/week and consumer directed personal assistance program (CDPAP) services 7 hours/day, 1 day/week following a telephonic assessment performed assessing the patient at total assistance with the tasks of ordinary housework, managing finances, and shopping while maximum assistance with tasks of meal preparation, managing medication, stairs, transportation, bathing, dressing lower body, and transfer toilet. With the tasks of personal hygiene, dressing upper body, walking, locomotion, and bed mobility the patient was assessed at extensive assistance while limited assistance with the task of phone use. The patient was assessed at supervision with the task of eating.
There was a request to increase PCA services and the patient underwent another assessment assessing the patient at total assistance with the tasks of ordinary housework and managing finances while maximum assistance with the tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet. With the tasks of personal hygiene, dressing upper body, toilet use, and bed mobility the patient was assessed at extensive assistance while limited assistance with the task of phone use. The patient was assessed at supervision with the task of eating and notes from the assessment stated the patient lived alone and had a decline in activities of daily living (ADL) status over the last 90 days as well as a deterioration of overall self-sufficiency in the last 90 days.
The insurer sent an initial adverse determination denial notice denying the request to increase PCA services stating the request was not medically necessary and they made a recommendation for an evaluation of durable medical equipment (DME) and a recommendation for a skilled nursing facility. The patient's cardiologist provided a letter stating the patient had significant mobility issues and was prone to falls and had significant issues with her hearing and required continuous assistance. The provider recommended increased hours and home health services. The patient's optometrist provided a letter stating the patient had macular degeneration in both eyes with legal blindness. The patient's primary care physician provided a letter documenting medical necessity for the patient to have extended home care services, specifically requiring at least 12 hours/day. The provider also noted the patient had a history of decreased hearing, decreased vision, gait disturbance, and spinal arthritis and the patient was inhibited from performing daily tasks such as bathing, dressing, and preparing foods on her own. The provider also noted the patient was very unsteady and weak making it difficult for her to get around and ambulate by herself and the patient had been having increased falls at home. In addition, the provider noted the patient was declining cognitively and was forgetting to take her medications which were critical for her health and aide services would be required for the entirety of her lifetime for safety and well being.
The patient's daughter provided a letter stating the requested increase in PCA services was medically necessary due to the patient's medical diagnoses. The daughter noted the patient was unable to do everyday chores and care for herself. Lastly, the daughter noted the patient was no longer able to dress herself, transfer herself on and off the toilet, or shower without assistance. The insurer provided a final adverse determination denial notice denying request to increase PCA/CDPAP services stating the current hours were appropriate to meet the patient's needs and granting additional hours was not provided when tasks were not being performed or for safety monitoring and supervision. The patient's healthcare advocate provided a request for appeal of the denial decision as well as noting the patient's medical diagnoses and need for increased PCA/CDPAP services. The patient and her family appealed denial decision.
At issue is the medical necessity of personal care aide (PCA) level 2: 12 hours per day- 6 days per week; consumer directed personal assistance program (CDPAP): 12 hours per day- 1 day per week- for a total of 72 hours per week.

The services are medically necessary. 

There is documentation of cognitive and functional decline of the patient by her medical providers and daughter. There is also documentation of legal blindness by her optometrist. There is documentation of increased assistance needs with tasks of walking and locomotion when comparing the assessments. 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 plan assumed the patient had informal help outside of the hours of currently assigned PCA and CDPAP services. The patient's needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with the safe completion of ADLs and 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 12 hours/day, 6 days/week, and CDPAP services 12 hours/day, 1 day/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.