Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Heart failure, chronic kidney disease, and complete heart block status post pacemaker placement
Treatment: Increase in Personal Care Aide (PCA) Services to 10 hours/day, 7 days/week, for a total amount of 70 hours/week
The insurer denied an increase in PCA services to 10 hours/day, 7 days/week, for a total amount of 70 hours/week.
The denial is partially overturned.

The patient is an elderly female with multiple medical comorbidities including heart failure, chronic kidney disease, and complete heart block status post pacemaker placement, The request was for an increase in Personal Care Aide (PCA) services to 10 hours/day, 7 days/week, for a total amount of 70 hours/week. Uniform Assessment System (UAS) evaluation completed 6 months ago reflects that the patient requires maximal assistance with bathing, toilet transfers and toileting, dressing, personal hygiene, bed mobility, walking, meal preparation, and eating. She requires extensive assistance with eating, and she is totally dependent for ordinary housework. A tasking tool completed at that time notes that the patient requires 7.5 hours/day, 52.5 hours/week to address her activities of daily living (ADLs). A final adverse determination notes that the original denial is upheld and that hours remain at 6 hours/day, 5 days/week; 5 hours/day, 2 days/week for a total of 40 hours/week. The letter states that time has already been allocated for ADLs, that additional hours are not provided when tasks are not being performed, and that the increase in hours is not medically necessary.

An appeal letter argues that the patient requires significant assistance with ADLs and that the increase to 70 hours/week is based on the recommendation of her hospice physician. A physician note indicates that the patient is frail and weak and "requires total care." Additionally, the patient's daughter also writes that the patient "needs assistance with all of her day to day tasks."

The proposed increase in PCA services to 10 hours/day, 7 days/week, for a total amount of 70 hours/week is not medically necessary. However, an increase to 52.5 hours/week is medically necessary.

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. The request is for an increase in home/personal services to 10 hours/day, 7 days/week, for a total amount of 70 hours/week. Based on the most recent in-home nursing assessment and tasking tool, the patient's functional status is such that 7.5 hours/day (for a total of 52.5 hours/week) are required to adequately meet her needs. Based on the tasking tool, there are ADLs which cannot be completed within the currently approved 40 hours/week. However, the appeal documentation does not reflect that there are ADLs which cannot be completed within the 52.5 hours/week estimated by the tasking tool and for which 70 hours/week are required. The plan notes that the patient also has appropriate medical equipment in the home, including bedside commode, cane, hospital bed, nebulizer, oxygen, raised toilet seat, shower chair, shower grab bar, walker (seated rollator), wheelchair and incontinence supplies which can assist with the patient's needs. Additional hours beyond the estimated 52.5 hours from the tasking tool would thus be primarily for supervision and safety concerns. Based on the available information, the plan approved hours (40 hours/week of PCS) are not sufficient to adequately meet the patient's needs. However, the proposed treatment (increase in PCA services to 70 hours/week) exceeds the patient's needs and is thus not medically necessary. An increase to 52.5 hours/week, as based on the recent in-home nursing assessment, is medically necessary and appropriate.