Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease. 
Treatment: Personal Care Assistance. 

The insurer denied Personal Care Aide (PCA) Level 2 Services: Total of 56 Hours per Week (8 Hours per Day, 7 Days per Week). The health plan's determination is overturned. 

The patient is a female with past medical history of asthma, coronary artery disease, hypertension, peripheral artery disease, chronic vertigo, diabetes mellitus with retinal complications, anxiety, glaucoma, rectal polyp, and lung mass who had been assigned PCA (personal care assistant) services. There was a request to increase PCA services and the patient went under telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, stairs, equipment management, bathing, and dressing lower body. The patient was assessed at limited assistance with tasks of phone use, transportation, dressing upper body, walking, and locomotion while supervision with managing medication and transfer toilet. With the tasks of personal hygiene, toilet use, bed mobility, and eating the patient was assessed as independent. Notes from the assessment stated the patient had occasional incontinence, had shortness of breath at rest. 

Increase in Personal Care Aide (PCA) Level 2 Services: Total of 56 Hours per Week (8 Hours per Day, 7 Days per Week) was medically necessary for this patient. 
The patient has documented progressive medical conditions of COPD (chronic obstructive pulmonary disease), diabetes with retinal complications, a lung mass which was likely cancer, and a rectal polyp that was likely cancer. There is documentation within the PCP (primary care provider) letter stating the patient requires increased assistance with eating, bathing, toileting, and dressing but the plan assessed the patient as independent with task of eating, toilet use, and personal hygiene which was an underestimation of her assistance needs. The patient therefore requires at least set up/limited assistance with all activities of daily living (ADL) / Instrumental activities of daily living (IADL) tasks except bed mobility. The patient would require assistance outside of the time she has informal help. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not formulate a plan to meet these unscheduled and unpredictable care needs. The patient's ADL/IADL assistance needs cannot be met with the currently assigned hours and/or adaptive equipment and/or medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 8 hours per day, 7 days per week, to total 56 hours per 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.