Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness, Unsteady Gait
Treatment: personal care aide level 2 (PCA) 7 hours per day-4 days per week; consumer directed personal assistance program (CDPAP) 4 hours per day-3 days per week-total of 40 hours per week
The insurer denied personal care aide level 2 (PCA) 7 hours per day-4 days per week; consumer directed personal assistance program (CDPAP) 4 hours per day-3 days per week-total of 40 hours per week
The determination is overturned.

The patient has a past medical history of hypertension, dizziness, osteoarthritis, diabetes mellitus, varicose veins, urinary incontinence, hypothyroidism, and neuropathy who had been assigned personal care assistant (PCA) services 4 hours/day, 5 days/week and Consumer Directed Personal Assistance Program (CDPAP) services 4 hours/day, 2 days/week, to total 28 hours/week of PCA/CDPAP services based on an assessment tool. The patient was assessed at limited assistance with task of equipment management, dressing lower body and managing medication while set up with task of managing finances. The patient was assessed as independent with task of bed mobility and eating.
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, and shopping while extensive assistance with tasks of managing medication, stairs, transportation, bathing, and transfer toilet. The patient was assessed at limited assistance with tasks of managing finance, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and bed mobility. With the task of phone use, the patient was assessed at set up while independent with task of eating. The insurer sent an initial adverse determination denial notice denying request to increase PCA/CDPAP services.
The insurer sent a final adverse determination denial notice denying request to increase PCA/CDPAP services stating the request was not medically necessary and the patient did not meet criteria. The denial further stated current hours were sufficient to meet the patient's care needs. The denial stated granting additional hours were not provided when tasks are not being performed. The patient's primary care physician (PCP) provided a letter stating the patient's medical diagnoses and the patient had limited mobility, ambulated with a cane, experienced dizziness, and needed assistance with personal care with an upgrade in her personal care services. Care need logs were provided noting the patient needed assistance with walking, locomotion, and toilet use, in addition to assistance with meal preparation and personal hygiene throughout the day.
The patient provided a letter stating she lived at home alone with minimal help, had unsteady gait and dizziness and was at high risk for falls which had happened a few times in the last month. The patient noted the attendant is not able to prepare dinner during their hours and after the attendant leaves the patient does not have help with toileting, getting dressed, and shower. Lastly, the patient letter stated she needed full time help with toileting, walking, and transferring around the house as well as daily functioning tasks.
At issue is the medical necessity of personal care aide level 2 (PCA) 7 hours per day-4 days per week; consumer directed personal assistance program (CDPAP) 4 hours per day-3 days per week-total of 40 hours per week.

The requested services are medically necessary.
There is documentation of a decline in physical functioning when comparing the assessments. The patient's primary care physician documented the medical necessity for increased PCA/CDPAP hours. Logs from PCA/CDPAP documented the assistance needs of the patient. The patient requires at least limited assistance with all ADLs/instrumental activities of daily living (IADLs) except eating. The patient does not have assistance with walking, locomotion, transfer toilet, and toilet use after her aide leaves. The requested increase in PCA/CDPAP hours is not solely for safety and supervision but to assist the patient with safe completion of ADL/IADLs. The patient's care needs cannot be met solely with adaptive equipment and/or medical supplies. 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 7 hours/day, 4 days/week, to total 28 hours/week and CDPAP services 4 hours/day, 3 days/week, to total 12 hour/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.