Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary tract infection, Incontinence
Treatment: Personal Care Assistance (PCA) Level II services 56 hrs per week
The insurer denied Personal Care Assistance (PCA) Level II services 56 hrs per week. 
The determination is overturned.

This is a female patient with a history of hypertension, congestive heart failure, hyperlipidemia, hypothyroidism, history of right renal transplant, severe protein-calorie malnutrition, and urinary incontinence. The patient was previously approved for Personal Care Assistance (PCA) services for 21 hours per week. The patient and her care team requested PCA services for 56 hours per week. The Plan partially denied this request and approved PCA services for 35 hours per week. The patient's daughter appealed this denial.
The patient has been residing at a nursing home facility. She had been admitted for generalized weakness after a urinary tract infection (UTI) with an acute kidney injury. Her attending physician at her nursing home facility states that the patient would benefit from an increase in home attendant services. She states that the patient requires extensive to total assistance with all her activities of daily living (ADLs) including transfer in and out of bed or chair, bathing, dressing and ambulation, and assistance with Instrumental activities of daily living (IADLs) including living, shopping, meal preparation, and house cleaning.
A video Uniform Assessment System (UAS) was completed at the patient's nursing home facility. The patient was assessed at total dependence for tasks of meal preparation, ordinary housework, and stairs; maximal assistance for tasks of managing finances, managing medications, shopping, and transportation; extensive assistance for tasks of bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility; limited assistance for phone use, personal hygiene, and dressing upper body; and supervision for eating. A tasking tool was used to determine that she requires 35 hours of aide service per week. At issue is the medical necessity of Personal Care Assistance (PCA) Level II services 56 hrs per week. 

Taking into account plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Assistance (PCA) services for 56 hours per week is medically necessary.
Managed Long Term Care (MLTC) policy 16.07 states that Plans must assure that the plan of care that is developed can meet any unscheduled or recurring daytime or nighttime needs that the enrollee may have for assistance. There is documentation in the UAS of the patient requiring extensive assistance with the tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs. The Plan should not have utilized a tasking tool to calculate hours given that the patient has unscheduled and unpredictable care needs. There is documentation from the patient's attending physician of the medical necessity of increased PCA services.
In the community, the patient lives alone and does not have informal support for the entire time outside of the previously assigned PCA hours.