Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of Falling. 
Treatment: Personal care worker (PCW) services 7 days per week, 8 hours per day.
The insurer denied the Personal care worker (PCW) services 7 days per week, 8 hours per day. 

The determination is overturned. 

The patient has a past medical history of diabetes mellitus type 2, coronary artery disease, ischemic cardiomyopathy, chronic kidney disease, hearing loss, gout, gastroesophageal reflux disease (GERD), obesity, anemia, and atrial fibrillation on chronic anticoagulation who had been assigned personal care assistant (PCA) services 4 hours/day, 7 days/week, to total 28 hours/week based on assessment tool performed over the phone. The assessment noted the patient at maximum assistance with tasks of meal preparation and ordinary housework while extensive assistance with tasks of stairs, shopping, transportation, equipment management, bathing, and dressing lower body. The patient was assessed at limited assistance with tasks of managing finances, dressing upper body, walking, locomotion, transfer toilet, and eating. With the tasks of managing medication and phone use the patient was assessed at set up only while independent with the tasks of toilet use and bed mobility. The notes from the assessment stated the patient used a cane indoors and rollator outdoors.
The patient scored 17/30 on a Mini-Mental State Examination (MMSE). Following this assessment, the PCA hours were increased to 5 hours/day, 7 days/week, to total 35 hours/week. The patient had a fall with a fracture of the left fibula with subsequent transfer to rehabilitation. There was a request to increase PCA hours to 8 hours/day, 7 days/week, to total 56 hours/week based on occupational therapy (OT), physical therapy (PT) and physician assessment. 

The patient's dermatologist provided a letter stating the patient fell on the day he was discharged to home from rehabilitation facility. The patient had to be sent to the hospital and stayed two days. The letter further stated the patient needed 24 hour home care. The plan sent a final adverse denial determination notice partially denying request for increase in PCA services, increasing PCA services to 6 hours/day, 7 days/week, to total 42 hours/week. The denial letter stated the request for increase in PCA hours was not medically necessary and did not meet criteria. In addition, the denial letter stated the discharge summary from rehabilitation stated the patient was able to walk 40 feet x 3 with contact guard assistance and the use of assistive device, was able to transfer with stand by assistance, was able to use the toilet with contact guard assist, was able to propel himself in wheelchair for 150 feet with supervision, was able to feed himself with set up help, and the patient was able to direct his own care. The denial letter noted the patient had visiting nursing services, physical therapy, and durable medical equipment (DME) in the home following his discharge from rehabilitation. The denial letter also stated the plan is not required to include safety monitoring as a separate task when calculating PCA hours. The patient's tenant service coordinator provided a letter stating the patient's mobility had declined and the patient has had multiple falls as well as his concerns for a life threatening fall for the patient. The patient's orthopedist provided a letter stating the patient had a significant musculoskeletal injury and has limited mobility and limited ability to care for himself and would benefit from home assistance. The patient's provided appealed the denial decision. The patient's daughter provided appeal letter stating the patient resides alone and requires assistance in all areas of functioning at home. She further stated the patient has difficulty with reaching the bathroom and preparing something to eat after the PCA has left. The daughter also noted she requested the home care agency to send a nurse to his home to assess his current functioning and was told it could not be done, limiting the amount of medical documentation for the patient's case. 

At issue is the medical necessity of personal care worker (PCW) services 7 days per week, 8 hours per day. 

The services are medically necessary. The patient has multiple medical diagnoses with the need for PCA services prior to a fall and resultant 2.5 month rehabilitation stay. The facility assessed the patient with OT and PT services and recommended PCA services 8 hours/day, 7 days/week to total 56 hours/week. The patient had documented assistance needs with tasks of walking, locomotion, transfer toilet and use of toilet with either stand by assistance or contact guard assistance. The patient did not have another assessment tool performed following his fall with a left leg fracture and 2.5 month rehabilitation stay. The patient lives alone and requires assistance with tasks when an informal helper is not available. The 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)/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 8 hours/day, 7 days/week, to total 56 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.