Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Falls
Treatment: Personal care services - 10 hours a day, 7 days a week, totaling 70 hours a week
The insurer denied personal care services - 10 hours a day, 7 days a week, totaling 70 hours a week.
The determination is overturned.


The patient has a past medical history of right hemiplegia, osteoarthritis, chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, permanent pacemaker, history of colon cancer, oxygen dependence, bilateral lower extremity lymphedema, and urinary incontinence. The patient was assigned personal care assistant (PCA) services 7 hours/day, 7 days/week. There was a request to increase PCA services and the patient underwent a telehealth assessment tool assessing the patient at total assistance with the tasks of ordinary housework and stairs while maximum assistance with the tasks of meal preparation, shopping, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. With the tasks of managing finances, managing medication, transportation, equipment management, personal hygiene, dressing upper body, and eating, extensive assistance, while limited assistance with tasks of phone use and bed mobility.

Notes from the assessment stated the patient lived alone, had an increase in falls, had functional decline over the last several months, had increased weakness, and the patient's daughter attempted to provide overnight assistance but this was difficult due to the daughter's own work schedule. The insurer sent an initial adverse determination denial notice denying the request to increase PCA services. The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating the patient's daughter was supportive, that aides cannot manage behaviors or medical conditions, that an aide cannot always be with the patient to prevent falls and injuries.
At issue is the medical necessity of personal care services - 10 hours a day, 7 days a week, totaling 70 hours a week.

Yes, the services are medically necessary.

There is documentation of worsening functional and cognitive impairment. There is also documentation that the patient's daughter cannot provide informal help outside of all of the hours of PCA services. The patient requires at least maximum assistance with tasks of walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet the patient's unscheduled and unpredictable care needs. The patient requires PCA services outside of the hours that she has informal help. The requested 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 10 hours/day, 7 days/week, to total 70 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 her own home.