Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID 19 (coronavirus 2019) complications.
Treatment: Personal Care Worker (PCW) services- 7 days per week, 6 hours per day, 42 hours per week.
The insurer denied Personal Care Worker (PCW) services- 7 days per week, 6 hours per day, 42 hours per week. The determination is overturned.

The patient has a past medical history of hypertension, coronary artery disease, congestive heart failure, urinary incontinence, frequent falls, chronic pain, osteoarthritis, and recent coronavirus 2019 (COVID-19) infection with post infection complications who had been assigned personal care assistant (PCA) services 26 hours/week. The patient had a COVID-19 infection with subsequent complications of chronic fatigue, shortness of breath, generalized muscle weakness, a dry cough, and loss of stamina.

There was a request to increase PCA services to 42 hours/week. A provider letter notes the patient's diagnoses of post-viral syndrome, status post COVID-19 pneumonia, hypertension, rheumatoid arthritis, low back pain, psoriasis, and urinary incontinence with symptoms of persistent headache, dizziness, and poorly controlled hypertension. The letter stated that the patient has significant limited ability to ambulate due to progressive rheumatoid arthritis and psoriatic arthritis and the patient needs personal assistance with any activities of daily living (ADL). The patient had an assessment tool performed via telephone assessing her at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs and transportation. The patient was assessed at limited assistance with tasks of equipment management, bathing, dressing lower body, and eating while supervision with task of medication management. The patient was assessed at independent with tasks of managing finances, phone use, personal hygiene, dressing upper body, transfer toilet, toilet use, and bed mobility. The patient scored 22/30 on a Mini-Mental State Examination (MMSE).

The insurer sent a final adverse determination denial notice stating the current level of care is enough to meet the patient's needs and the plan is not required to include safety monitoring as a separate task or calculate any minutes allotted for safety monitoring as part of the total personal care services. The letter indicated that the plan spoke to the patient at which time, the patient stated she needed assistance with bathing, cooking, cleaning, shopping, to accompany walking outdoors and to medical appointments. It also stated the patient needed limited help to transfer and to use the toilet and was able to walk utilizing a cane. A walker and services for physical therapy (PT) were recommended by the insurer but the patient declined. The patient appealed the adverse decision.

The patient's primary care physician (PCP) provided a letter requesting an urgent increase in home care for the patient due to her rapidly deteriorating mental state and physical health. The letter further states the patient lives alone, is home bound, has grossly limited range of motion (ROM), is unable to ambulate independently without the use of an assistive device, and continues with symptoms of fatigue, shortness of breath, dry cough, palpitations, muscle weakness, stamina loss, and severe ADL limitation due to recent COVID-19 infection with post-viral fatigue syndrome. The letter also states the patient is unable to independently carry out normal activities of daily living and needs assistance from her home health aide. Her PCP further stated that due to her physical decline the patient can no longer perform normal activities of daily living such as cooking, cleaning, bathing, dressing, grocery shopping, lifting objects, reaching overhead, fine and gross motor skill tasks and maintaining her household. The provider stated that it is medically necessary for the patient to receive 8 hours of home care daily, 7 days/week to maintain her current health and prevent her from illness prevention.

The requested services are medically necessary. The patient has a documented decline in functional status related to post COVID-19 disease with increased fatigue, muscle weakness, and decreased stamina since her assessment that assessed her PCA care needs at 26 hours/week. The telephonic assessment tool underestimated the patient's care needs. The final adverse determination denial notice states the insurer spoke to the patient and noted she needs assistance with transferring on/off toilet and toilet use although she was assessed as independent with these tasks. Toilet use and transfer toilet are unpredictable and unscheduled task/care needs and the insurer did not incorporate time needed to safely complete these tasks. The patient's current PCP provided a letter of medical necessity for an increased PCA hours, specifically requesting 8 hours/day, 7 days/week. 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. An increase in PCA service hours for this patient is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs).