Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis
Treatment: Personal Care Assistance
The insurer denied Personal Care Assistance.
The determination is overturned.

The patient has a past medical history of a pulmonary embolism, severe protein malnutrition, constipation, hypertension, hypothyroidism, insomnia, depression, chronic pain, urinary incontinence, bowel incontinence, hyperlipidemia, and hip and knee arthritis who had been assigned personal care assistant (PCA) service hours 5 hours/day x 5 days, 4 hours/day x 1 day, and 3 hours/day x 1 day. The patient had an assessment tool performed assessing the patient at total assistance with tasks of ordinary housework and shopping while maximum assistance with meal preparation and transportation. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, stairs, bathing, dressing upper/lower body, transfer toilet, and toilet use while limited assistance with tasks of phone use, personal hygiene, walking, and locomotion. With the task of bed mobility the patient was assessed at supervision only and independent with task of eating. In the records provided for review there was a prior external appeal from approving PCA services 56 hours/week.
There was a request to increase PCA services and the patient underwent a telephonic assessment tool assessing the patient at total assistance with meal preparation, ordinary housework, bathing, walking, locomotion, and transfer toilet while maximum assistance with managing finances, stairs, shopping, dressing lower body, and toilet use. With tasks of managing medication, transportation, personal hygiene, dressing upper body, and bed mobility the patient was assessed at extensive assistance while limited assistance with tasks of equipment management and eating. Notes from the assessment stated the patient lives alone, used a wheelchair indoors and outdoors, and required a Hoyer lift for transfers. The patient was hospitalized with the diagnosis of deep vein thrombosis (DVT) and pulmonary embolism, was transferred to rehabilitation on and was placed on hospice care in that facility. The insurer sent an initial adverse determination denial notice denying to increase PCA services to 24 hours/day, 7 days/week. This denial stated that the patient was a  bedbound female. The denial stated that the patient was now a 2 person extensive assistance with toileting and transfers and the patient's two healthcare proxy's would not consistently be available to assist the patient with two person and skilled care needs throughout the day. In addition, the denial letter stated the patient has skilled care needs that exceed a PCA's scope of practice and that the patient uses oxygen via nasal cannula, required extensive assistance with managing 13 medications including the application of a fentanyl patch and a bisacodyl rectal suppository. The denial also stated that the patient required wound care treatment to her sacrum twice daily as needed. The patient was then transferred to an extended care facility. The patient's advocate requested and external appeal of denial decision by the insurer.
The extended-care facility notes stated that the patient was able to eat with the assistance of one person, transfer with the assistance of two people, bed mobility and locomotion with one person assist, toileting, bathing, hygiene and dressing with one person assist and mobility was noted to be extensive with one person assist. The patient's friend and neighbor provided a letter stating that prior to patient being in the nursing home she did help direct home care attendance for the patient. The friend indicated that she is familiar with the patient's needs and had visited her in the nursing home and was familiar with the patient's current condition and needs. This friend was also willing to be responsible for medication administration, specifically administering a Fentanyl patch. The friend's letter also stated that the patient has never used oxygen in the home that she was aware of.
The nursing home physician provided a letter stating the patient's medical diagnoses, the patient can safely be transferred to and from bed using a Hoyer lift in her home with the assistance of one person, the patient does not need oxygen, the patient will not need bisacodyl rectal suppository upon discharge from the facility, and that the patient's only skilled need will be the administration of fentanyl transdermal patch which the patient's friend has agreed to be responsible for. This letter from the provider also noted that due to her incontinence of bladder and bowel, the patient needs to have her diaper changed at unpredictable times throughout the day and night and because of her history of pressure sores she needs frequent and timely incontinence care to prevent further skin breakdown. The provider lastly stated that the patient is safe and appropriate to be discharged to home with 24-hour personal care services. The patient's healthcare advocate wrote another letter in support of an external appeal of denial of 24-hour split shift PCA services.
At issue is the medical necessity of Personal Care Assistance.
The Personal Care Assistance is medically necessary for this patient.
The patient has documented chronic medical conditions of bowel incontinence, bladder incontinence, osteoarthritis, pressure ulcers, memory impairment and malnutrition. There has been a decline in patient's cognitive and functional status from the latest assessment to the prior assessment. In addition, there is further decline in her functional and cognitive status as documented by rehabilitation and extended care facility notes. The plan denied the request for increased PCA services citing the patient had care needs that required the assistance of 2 people and the patient had skilled care needs that were out of the scope of a PCA. However, the patient's nursing home provider documented in a letter that the patient was safe to be discharged to home with one-person assistance and her only skilled care need would be the administration of fentanyl patch which her friend has stated she will perform.
The patient has unpredictable and unscheduled care needs over a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has care needs in the overnight hours with incontinent care and repositioning with history of urinary and bowel incontinence as well as pressure ulcers. The patient's care needs would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The increase of PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met with adaptive equipment and medical supplies alone or in combination with 56 hours/week of PCA services. The patient's medical provider documented medical necessity for increase in PCA hours. 
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 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.