Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure. 
Treatment: Increase in personal care assistance (PCA) to 24 hours per day 7 days a week, split shift or a total of 168 hours per week. 

The insurer denied an increase in personal care assistance to 24 hours per day 7 days a week, split shift or a total of 168 hours per week. 

The determination is upheld. 

The patient has a past medical history of osteoporosis, coronary artery disease, hypertension, congestive heart failure, hyperlipidemia, hypothyroidism, diabetes mellitus type 2 with neuropathy, chronic kidney disease, hearing loss, proliferative diabetic retinopathy, lumbar spinal stenosis, osteoarthritis, and urinary incontinence who had been assigned personal care assistant (PCA) services 63 hours/week. 

The patient was hospitalized for shortness of breath. There was a request to increase PCA services and the patient underwent a telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing medication, stairs, shopping, and transportation while extensive assistance with tasks of managing finances, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. With the task of phone use the patient was assessed at limited assistance and independent with task of eating. Notes from this assessment stated the patient had unstable gait and experienced dizziness. In addition, the assessment stated the patient was using 2 liters (L) of oxygen and ambulated indoors with a Rollator, and used a wheelchair outdoors. The assessment also stated the patient needed help to use the toilet and patient was unable to walk without assistance. 

The patient's primary care provider wrote a letter stating the patient was unable to ambulate more than 10 feet without experiencing severe shortness of breath and fatigue, was dependent on supplemental oxygen for all physical activity except for short walks, was dependent in most activities of daily living, and must not be left alone. The primary care physician's letter also stated that the patient's home attendant support should be increased to 24 hours, 7 days/week given her risk for injury or abrupt progression of illness when alone and need for in-home support as she lives alone.
The insurer sent a final adverse determination denial notice denying quest to increase PCA services and stating the PCA hours given under the last authorization or reauthorization were still enough to meet the patient's needs. The denial also stated the plan would continue to approve her current hours per week which was enough to support her current activities of daily living. In addition, the denial letter stated the patient's needs may be temporary and may be met with short-term skilled home care services. The denial also stated personal care assistant services were not covered for safety and supervision alone. Lastly, the denial stated the patient did not have nighttime needs such as nighttime changing of incontinence products or decubitus ulcer.
The patient appealed the denial decision. Notes from the appeal stated the patient had been hospitalized after a fall in her home when alone, had progressive congestive heart failure (CHF), had issues with being able to stand/walk, and needed oxygen after short exertion. 

At issue is the medical necessity of increase in personal care assistance to 24 hours per day 7 days a week, split shift or a total of 168 hours per week. 

The services are not medically necessary. 

Although the patient has had hospitalizations with the need for assistance with standing, walking, and other activities of daily living (ADLs), there is no documentation that the patient has overnight needs such as frequent toileting, frequent incontinence cares, or the need to be repositioned and turned every 2 hours. The patient does have assistance needs with all ADLs/instrumental activities of daily living (IADLs) except eating. The patient is approved for 63 hours a week. 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 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are not medically necessary for this patient.