Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified Osteoarthritis
Treatment: Home Health Care/Personal Care Aide (PCA) Level 2: live-in per diem: 1 day-7days per week - for a total of 7 days per week. 
The health plan denied the requested health service/treatment of Personal Care Aide (PCA) Level 2: live-in per diem: 1 day-7days per week - for a total of 7 days per week as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a past medical history of osteoarthritis, urinary incontinence, dementia, and hypertension who had been assigned personal care aide (PCA) services 4 hours/day, 7 days/week, to total 28 hours/week based on video assessment performed, assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, stairs, shopping, and transportation. With the tasks of bathing and dressing lower body, the patient was assessed at extensive assistance, while supervision with tasks of managing medication, walking, locomotion, and transfer toilet. The patient was assessed at independent with tasks of phone use, personal hygiene, dressing upper body, toilet use, bed mobility, and eating. There was a request to increase PCA services and the patient underwent an in-person assessment assessing the patient at total assistance with tasks of ordinary housework, managing finances, stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use while maximum assistance with tasks of meal preparation, managing medication, shopping, and bed mobility. The patient was assessed at extensive assistance with task of dressing upper body and independent with the task of eating. Notes from the assessment stated the patient had a decline in activities of daily living (ADL) status over the last 90 days and deterioration of overall self-sufficiency in the last 90 days. The patient's primary care physician (or provider) (PCP) provided a letter requesting an increase in home health aide coverage to 2, 12-hour split shift, 7 days/week and the patient was homebound and no longer able to walk or get out of bed. The letter also stated the request was medically necessary and failure to provide her with the requested home health aide coverage may place the patient's health at significant risk. 

The health plan's determination of medical necessity is overturned, in whole.

There is documentation from the patient's medical provider and family of worsening physical and cognitive functioning. The patient had significant increase in assistance needs with multiple ADLs, specifically, on the most recent Uniform Assessment System (UAS) assessment, the patient was total assistance with tasks of walking, locomotion, transfer toilet, and toilet use when she had been assessed at supervision for all of those tasks except with toilet use was assessed as independent on the last UAS. The patient has 24-hour care needs and therefore the plan should not have utilized a task-based tool to calculate PCA hours. The patient has unscheduled and unpredictable care needs that span a continuum of time. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, Personal Care Aide (PCA) Level 2: live-in per diem: 1 day-7days per week - for a total of 7 days per 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.