Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Home Health Care 
The insurer denied an increase in Personal Care Aide (PCA) Level 2 for medical necessity. 
The denial was overturned. 

The patient is a male with a past medical history of atrial fibrillation on chronic anticoagulation, coronary artery disease, constipation, bladder incontinence, bunion and overlapping toes with gait abnormality, depression, anxiety, dementia, benign prostatic hyperplasia (BPH), and osteoarthritis. The patient had a fall with left elbow fracture and hospitalization with subsequent stay at rehabilitation. The patient was assigned Personal Care Aide (PCA) services 5 hours/day, 7 days/week, to total 35 hours/week.

There was a request to increase PCA services and the patient underwent another telephonic assessment, assessing the patient at total assistance with meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of phone use, stairs, transportation, bathing, dressing upper/lower body, walking, and locomotion. The patient was assessed at extensive assistance with tasks of managing medication, personal hygiene, transfer to toilet, toilet use, and bed mobility while limited assistance with task of eating. The patient was incontinent of urine, required aide assistance under both underarms and across back and significant weightbearing help with walking and locomotion, required some weightbearing assistance to help transfer on and off the toilet seat, and required help with perineal hygiene and supported arms to change diaper, put pants back on and re-button pants.

The patient's provider sent a letter stating the patient had diagnoses of dementia and behavioral disturbance with dysthymic disorder with additional psychological conditions of depression, anxiety, dysphoria, fragmented sleep, memory problems, and inability to plan and organize daily activities. 

The insurer provided final adverse determination denying request to increase PCA services but partially approving PCA services at 6 hours/day, 7 days/week, to total 42 hours/week. PCA services would be raised and additional hours are not provided when tasks are not being performed.

At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 12 Hours per Day, 7 Days per Week, Total of 84 Hours.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 Hours per Day, 7 Days per Week, Total of 84 Hours per Week is medically necessary for this patient.

The patient has documented chronic progressive medical conditions of dementia, osteoarthritis, bladder incontinence, and foot deformities which limit his independent mobility. The patient's medical provider documented a medical necessity for increased PCA services, specifically recommending 24 hour/day, split shift, PCA services. It was noted the patient had bladder incontinence and had urinary events up to 10 times at night. The patient requires at least limited assistance with all activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient is on anticoagulant medication, putting him at higher risk for morbidity with falls. 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.

Therefore, the requested service of Personal Care Aide (PCA) Level 2: 12 Hours per Day, 7 Days per Week, Total of 84 Hours per Week is medically necessary.