Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal - Osteoporosis. 
Treatment: Home Health Care.
The insurer denied Increase in Personal Care Services(PCS); Live-in 24-hour personal care services for a total of 91 hours.
The denial is overturned. 

The patient is a female with a past medical history of vestibular disorder, osteoporosis, urinary incontinence, hypothyroidism, and lower extremity edema who had been assigned personal care aid (PCA) services 7 hours/day, 6 days/week and 6 hours/day, 1 day/week to total 48 hours/week. The patient had visiting nurse (VNS) services with documented note. There was a request to increase PCA services and the patient underwent a video assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and stairs while maximum assistance with tasks of managing finances, shopping, transportation, bathing, and dressing lower body. With tasks of managing medication, phone use, equipment management, personal hygiene, dressing upper body, transfer to the toilet, and toilet use, the patient was assessed at extensive assistance while limited assistance with tasks of walking, locomotion, and bed mobility. With the task of eating the patient was assessed at supervision. Notes from the assessment stated the patient utilized a cane and had no informal help.
The patient saw her primary care physician (or provider) (PCP) with office note stating the patient had decreased energy, difficulty transferring to walker, unsteady gait utilizing walker, memory decline, and difficulty focusing on tasks.
DOH 4359 was completed stating due to history of falling, cognitive decline, incontinence, and need for assistance with transfers and ambulation, 24-hour care was medically necessary and prognosis for recovery was poor. The form stated the patient suffered from mixed incontinence and was using depends and required overnight assistance for toileting and personal hygiene.
At issue is the medical necessity of Increase in Personal Care Services(PCS); Live-in 24-hour personal care services for a total of 91 hours.

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

Yes, the requested health service/treatment of Increase in Personal Care Services(PCS); Live-in 24-hour personal care services for a total of 91 hours is medically necessary for this patient.
There is documentation of medical necessity by the patient's PCP of increased PCA services, specifically the request for 24-hour care. The patient does have 24-hour care needs and therefore the plan should not have utilized a task-based assessment to calculate the patient's required hours. The patient requires extensive assistance with transfer to the toilet and toilet use while limited assistance with walking and locomotion and therefore has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient has no 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 (ADL)s and Instrumental activities of daily living (IADL)s. 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 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.
Therefore, the requested health service/treatment of Increase in Personal Care Services(PCS); Live-in 24-hour personal care services for a total of 91 hours is medically necessary.