Appeal type: Medical necessity
Decision: Overturned

Orthopedic/musculoskeletal. 
Nursing Services (including Private Duty Nursing). 

Diagnosis: Decreased mobility. 
Treatment: Personal Care Aide (PCA) Level 2 Services. 
The insurer denied Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day - 7 Days per Week + 12 Hours per Day - 7 Days per Week (Split Shift); Total of 168 Hours per Week. 

The health plan's determination is overturned. 

The patient is a male with past medical history of coronary artery disease, presence of pacemaker, hypertension, hyperlipidemia, diabetes mellitus type 2, benign prostatic hyperplasia (BPH), right orchitis, seizure disorder, acquired immunodeficiency syndrome (AIDS), inclusion body myositis, depression, cerebrovascular accident (CVA) with bilateral hand contractures, right shoulder impingement, history of bladder tumor, deep vein thrombosis (DVT) with inferior vena cava (IVC) filter, osteoarthritis, posterior reversible leukoencephalopathy, urinary incontinence, and bowel incontinence who had PCA (personal care aide) services based on assessment tool performed assessing the patient at total assistance with tasks of ordinary housework and locomotion while maximum assistance with tasks of meal preparation, shopping, transportation, bathing, personal hygiene, dressing upper/lower body, walking, transfer toilet, toilet use, and bed mobility. The patient was assessed at extensive assistance with tasks of managing medication and eating while limited assistance with task of managing finances. 

The Requested Increase in Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day - 7 Days per Week + 12 Hours per Day - 7 Days per Week (Split Shift); Total of 168 Hours per Week is medically necessary for this patient. 

The patient has multiple progressive illnesses with documented decline in functional status. The patient had been in rehabilitation following hospitalization with physical therapy (PT) and occupational therapy (OT) noting the patient's functional decline with need for total assistance with ADLs and requirement of Hoyer lift for all transfers. The plan incorrectly assumed the patient had informal helper but he did not. The patient had 24 hour care needs including overnight assistance needs that would not allow an aide to obtain five hours of uninterrupted sleep. The patient's rheumatologist documented the medical necessity of increase in PCA hours. The patient has assistance needs with all ADLs/ Instrumental activities of daily living (IADL). Equipment and supplies would not adequately assist the patient's care needs when personal care aide is not present. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/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 24 hours/day, split-shift, 7 days/week, to total 168 hours/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 his own home.