Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cognitive Impairment. 
Treatment:  Level II Personal Care Aide (PCA) Services: 168 Total Hours per Week (24 Hours per Day, 7 Days per Week, Split-Shift). 

The insurer denied Level II Personal Care Aide (PCA) Services: 168 Total Hours per Week (24 Hours per Day, 7 Days per Week, Split-Shift.  The determination is overturned. 

The patient has a past medical history of osteoarthritis, unsteady gait, osteoporosis, chronic kidney disease stage 4, hypertension, hyperlipidemia, anemia, urinary incontinence, cognitive impairment, hearing loss, and insomnia and had been assigned personal care assistant (PCA) services 6 hours/day, 7 days/week to total 42 hours/week. The patient's primary care provider (PCP) provided a letter stating the patient's medical diagnoses, the need for help with the tasks of bathing, dressing, cooking, cleaning/laundry, and shopping, and that the patient would benefit from increase in home care hours. There was a request to increase PCA services and the patient underwent a telephonic assessment tool assessing the patient at total assistance with tasks of ordinary housework, stairs, and shopping, while maximum assistance with tasks of meal preparation, bathing, and dressing lower extremity. The patient was assessed at extensive assistance with tasks of managing medication, phone use, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet and supervision with task of eating. With the task of bed mobility the patient was assessed as independent. 
The nurse's notes from the assessment noted that the patient had moderate cognitive impairment, had to be coaxed to take a shower, wanders after the PCA leaves, is unable to use the microwave, lives alone and informal helpers (her children) are unable to contribute to care due to their own medical issues, uses a rollator and cane to ambulate, and has had recent falls without injury. The assessment tool stated the tasks of managing finances, transportation, and equipment management did not occur. The plan sent an initial adverse determination denial notice stating denial for a request to increase PCA hours to 24 hours/day, split-shift, 7 days/week and coverage stays at 6 hours/day, 7 days/week to total 42 hours/day. The plan provided a final adverse determination denial notice stating partial approval of the request to increase PCA hours to 12 hours/day, 7 days/week to total 84 hours/week. The denial letter also stated, based on the assessment that the patient did not meet the requirements for all of the additional hours that were requested. In addition, the denial letter stated that the patient was independent or needed just a little help with activities of daily living. Lastly, the denial letter stated that the plan does not cover care needs for general safety supervision outside of specific daily activities. 

The patient had an office visit with the PCP and the progress note stated that the patient was not sleeping well and was dependent on all activities of daily living (ADLs)/ instrumental activities of daily living (IADLs). The patient's PCP provided a letter stating the patient would benefit from an increase in home care hours. The patient/patient's family and patient's PCP appealed the denial decision. The patient underwent another assessment tool over the phone assessing her at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of phone use, stairs, transportation, equipment management, bathing, dressing lower extremity, and toilet use. The patient was assessed at extensive assistance with the tasks of managing medication, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet. With the tasks of bed mobility and eating, the patient was assessed at supervision only. The notes from the visit stated the patient was unable to state goals, the family never left the patient unattended, and informal helpers were no longer able to participate in care activities. At issue is the medical necessity of Level II Personal Care Aide (PCA) Services: 168 Total Hours per Week (24 Hours per Day, 7 Days per Week, Split-Shift). 

The services are medically necessary. The patient has progressive medical illnesses including dementia, chronic kidney disease, and osteoarthritis. The patient no longer has informal help by her family due to their own medical diagnoses. The patient needs at least extensive assistance with all ADL/IADL tasks except bed mobility and eating. The patient has unscheduled and unpredictable care needs over a continuum of time for which the insurer did not document a care plan to take these unscheduled and unpredictable care needs into account. The patient has 24-hour care needs and therefore the assessment tool should not have been utilized to calculate PCA hours. The patient needs assistance with toilet use and transfer toilet which are unpredictable and unscheduled care needs. An increase in PCA hours is not solely for supervision and safety but to assist the patient with safe completion of ADLs/IADLs. Taking into account all of the 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 her own home.