Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Services level 2, 12 hours per day, 7 days per week for a total of 84 hours per week
The insurer denied Personal Care Services level 2, 12 hours per day, 7 days per week for a total of 84 hours per week.
The determination is overturned.

The patient is a female with a past medical history of deep vein thrombosis (DVT), congestive heart failure (CHF), coronary artery disease (CAD), hyperlipidemia, hypertension, gastroesophageal reflux disease (GERD), depression, osteoarthritis, atrial fibrillation, and urinary incontinence who had been assigned personal care assistant (PCA) services 5 hours/day, 7 days/week to total 35 hours/week based on an assessment. A tasking tool estimated 21.8 hours/week.
The patient's podiatrist provided a letter noting the patient had severe impediment of her ability to walk and stand on her feet due to multiple conditions. The patient's primary care physician (or provider) (PCP) provided a letter stating the medical diagnoses, that the patient was homebound and had a history of frequent falls, unsteady gait, and poor balance, and that the patient had limited range of motion and severely impaired mobility and ambulated with a walker and one-person assistance. 
The patient underwent another assessment, in person. Notes from the assessment stated the patient had a decline in activities of daily living (ADLs) status over the last 90 days, had multiple documented falls, and had no informal help. A tasking tool estimated 34.1 hours/week.
The insurer sent a final adverse determination denial notice denying request to increase PCA services stating the patient did not meet criteria and personal care services were not authorized if the need for assistance could be safely met by using supplies light diapers, chucks, commodes, walkers, or wheelchairs. In addition, the denial stated hours were not provided for safety and supervision alone. The denial also stated that two independent home exams did not show the patient needed more than 34 hours/week and the patient also shared hours with her ex spouse who also got 42 hours/week and many of her needs were duplicated such as cooking, cleaning, and grocery shopping. At issue is the medical necessity of Personal Care Services level 2, 12 hours per day, 7 days per week for a total of 84 hours per week.
The services are medically necessary. There is documentation from the patient's medical provider of the medical necessity of increased PCA services. The provider specifically recommends 24 hours/day, 7 days/week. The plan's own assessment documented extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use and 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. Although the patient has shared services with her ex spouse, these hours do not account for the assistance she needs with unpredictable and unscheduled care needs. The patient has no informal help. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care 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 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient.