Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Weakness of the upper and lower extremities.
Treatment:  Personal care assistance - Level II 24 hours per day 7 day per week (live in). 
The insurer denied personal care assistance - Level II 24 hours per day 7 day per week (live in).  The determination is overturned.

This is a patient with a past medical history of depression, urinary incontinence, coronary artery disease, congestive heart failure, hypertension, constipation, osteoporosis, obesity, osteoarthritis, asthma and glaucoma who had been assigned personal care assistant (PCA) services 5 hours/day, 7 days/week to total 35 hour/week. The patient had a fall  and was hospitalized and subsequently diagnosed with klebsiella bacteremia secondary to choledocholithiasis.  Following hospitalization the patient was transferred to rehabilitation.  The patient was seen by a physical medicine and rehabilitation provider and was noted to have weakness of the upper and lower extremities.  The provider recommended ongoing use of a wheelchair, night splints, physical therapy (PT), occupational therapy (OT) and 24 hour care at home.
The patient had an assessment tool for PCA services performed.  The patient was assessed as needing total assistance with meal preparation and ordinary housework.  The level of assistance for tasks of stairs, shopping, transportation and bathing was assessed at maximum level.  Extensive assistance was assessed for the tasks of dressing upper and lower extremities and toilet use.  The assessment tool placed the patient's level of need for tasks of managing finances, managing medications, phone use, equipment management, personal hygiene, walking, locomotion, transfer toilet and bed mobility at limited, and she was deemed independent with eating.

The patient's son noted multiple inconsistencies with this report, specifically that the assessment reported no recent injury when the patient had just fallen and had been hospitalized.  On the assessment tool there was a noted "0" for emergency room visits when the patient had just been in the emergency department (ED) and was hospitalized.  It also noted that the patient was home alone for 1 hour per day when she was alone from 1 PM until 8 AM the next day.  The assessment tool documentation noted the patient always needs total help with managing finances, managing medications and phone use (hearing loss).  Since the patient's hospitalization, she is not able to maneuver stairs at all.  The patient had another consultation with the PMR physician, and they recommended 8-12 hours of homemaking services.  The patient had a denial of PCA services at 24 hours/day, 7 days/week.  The patient had another assessment tool performed, noting worsening ability to perform tasks of managing finances, managing medications, phone use, stairs, equipment management, personal hygiene, dressing lower extremity, walking, locomotion, transfer toilet, bed mobility and eating.  The nurse who did this assessment noted that the patient forgets to take her night time medication.  The report also noted the patient had limited mobility in both hands limiting her ability to open medication bottles.  The patient needs guidance with eating.  The assessment also noted that the patient had a deformity of her ankle making it difficult for her to walk steady, move from sit to stand, and member was noted to almost fall forward when trying to do this during her assessment.  The report also noted the patient had extreme difficulty getting in and out of bed and that she was at high risk for falls.  At issue is the medical necessity of personal care assistance personal care assistance - Level II 24 hours per day 7 day per week (live in).

The patient has multiple medical issues with multiple orthopedic issues making it difficult for her to transfer and walk.  She has unscheduled needs during the night hours, as she requires assistance with walking, bed mobility, toilet transfer, incontinence cares.  PCA services during the afternoon, evening and overnight are not just for companionship and supervision but for specific supervision of stand alone tasks that occur outside of the hours of PCA services.  The patient does not have an informal helper and requires 24 hour/day (live-in) PCA services to remain in the community.  The patient requires assistance with evening medication, as she often forgets and needs help with meal preparation, simple tasks and personal hygiene due to her significant hand arthritis.  All of these tasks occur in the afternoon and evening hours.