Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease (CAD).
Treatment: PCA (personal care assistant) services .
The insurer denied the Personal Care Services: 8 Hours per Day, 7 Days per Week (Total of 56 Hours per Week). 
The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, hypertension, congestive heart failure, constipation, hypothyroidism, osteoporosis, osteoarthritis, gastroesophageal reflux disease (GERD), depression, and urinary incontinence who had been assigned PCA (personal care assistant) services based on telephonic assessment tool performed assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with task of bathing while limited assistance with tasks of personal hygiene, dressing upper body, locomotion, transfer toilet, toilet use, and bed mobility. With the task of eating, the patient was assessed at supervision. There was a request to increase PCA services and the patient underwent telephonic assessment tool assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, shopping, transportation, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks managing finances, managing medication, equipment management, dressing upper body, walking, locomotion, transfer toilet, and toilet use while limited assistance with tasks of phone use and personal hygiene. With the tasks of bed mobility and eating the patient was assessed at supervision.

Personal Care Services: 8 Hours per Day, 7 Days per Week (Total of 56 Hours per Week) are medically necessary for this patient. 
Although letters were not provided for review, the denial letter from the insurer stated that the patient's PCP and psychiatrist noted a decline in the patient's physical and mental functioning. In addition, the patient's son could no longer provide informal help. The assessment tool performed several months ago indicated the patient had increased assistance needs with several tasks, including, bathing, dressing upper/lower body, locomotion, transfer toilet, and toilet use. The assessment also indicated the patient needed at least supervision assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL). The requested increase in assistance was not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The insurer made assumption of informal support which the patient no longer has. Taking into account the 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 when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.