Appeal type: Medical necessity
Decision: Overturned

Orthopedic/musculoskeletal
Home Health Care

Diagnosis: osteoarthritis
Treatment: Personal Care Aide (PCA) Services
The insurer denied Personal Care Aide (PCA) Services: 8 Hours per Day, 7 Days per Week (Total Amount of 56 Hours per Week). The health plan's determination is overturned. 

The patient is a female with past medical history of diabetes mellitus type 2, hyperlipidemia, osteoarthritis, and right leg pain who had been assigned PCA (Personal Care Aide) services based on assessment tool performed assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of managing medication and shopping. The patient was assessed at extensive assistance with tasks of meal preparation and transportation while limited assistance with tasks of managing finances, stairs, bathing, personal hygiene, and dressing upper/lower body. With the tasks of walking, locomotion, and transfer toilet the patient was assessed at supervision only while independent with tasks of phone use, toilet use, bed mobility, and eating. Notes from this assessment stated the patient requires oversight with ambulating and toilet transfer due to pain in the lower extremities related to osteoarthritis. This assessment also stated the patient required contact guidance with bathing and dressing lower body. There was a request to increase PCA services and the patient underwent a telephonic assessment assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, shopping, and transportation. The patient was assessed at extensive assistance with tasks of stairs, bathing, dressing lower body, walking, locomotion, and transfer toilet while limited assistance with tasks of managing finances, personal hygiene, and dressing upper body. With tasks of toilet use and bed mobility the patient was assessed at supervision only and independent with tasks of phone use and eating.

The Increase in Personal Care Aide (PCA) Services: 8 Hours per Day, 7 Days per Week (Total Amount of 56 Hours per Week) is medically necessary for this patient.
The patient has documented diagnosis of lumbar radiculopathy with worsening symptoms and worsening functional status as the recent assessment tool. The patient no longer has the same informal support that she previously had as her daughter has declining health and can only provide limited help. The patient requires assistance with all activities of daily living (ADL) / Instrumental activities of daily living (IADL) except phone use and eating. The patient had increased assistance needs with tasks of meal preparation, stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility when comparing to previous assessment tool. The patient has unscheduled and unpredictable care needs over a continuum of time and the patient would need PCA assistance outside of the time she has informal support. The combination of increased assistance needs with multiple tasks as outlined above and the fact that her daughter can no longer provide the same level of care supports the need for increased PCA hours. The increase in PCA hours is not solely and supervision alone but to assist the patient with safe completion of ADLs/IADLs. 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 8 hours/day, 7 days/week, to total 56 hours/week are medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.