Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Personal Care Aide Level 2: 9 hours per day, 5 days per week, 7 hours per day 2 days per week, a total of 59 hours per week. 
The denial is overturned.

The patient is a female with past medical history of osteoarthritis, diabetes mellitus type 2, melanoma, bladder incontinence, and hypertension who had been assigned Personal Care Assistance (PCA) services 7 hours/day, 5 days/week, and 5 hours/day, 2 days/week to total 45 hours/week based on assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, and shopping while maximum assistance with tasks of transportation, bathing, dressing lower body, and locomotion. With tasks of personal hygiene, dressing upper body, walking, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of managing finances, managing medication, phone use, and bed mobility. The patient was assessed at supervision with task of eating.

The health plan provided final adverse determination denial notice denying request to increase PCA services and stating the patient had adaptive equipment and medical supplies to assist her with her needs, granting additional hours were not provided when tasks were not being performed, and the request for increase was not medically necessary. The patient's daughter provided a letter appealing the denial decision stating the patient only left her house every 3 to 4 months when she needed to go to a medical provider such as her cardiologist or dermatologist and all other providers came to her home. The daughter's letter also stated the patient's family members could not assist with the patient's care as they all have full-time jobs and did not arrive home until 2 to 3 hours after the patient's aide leaves. In addition, the daughter's letter stated the patient's mother had fallen 4 times with one of the falls resulting in a hospitalization and subsequent rehab stay.
The subject under review is the medical necessity for 59 hours.

The health plan's determination is overturned.

The patient's daughter asserts that the telephonic assessment tool underestimated the patient's assistance needs with multiple tasks. Despite documentation that patient had no change in activities of daily living (ADL) status or self-sufficiency, the patient improved with tasks of meal preparation, managing medication, phone use, shopping, dressing upper body, locomotion, and eating when comparing the two assessments. In addition, the tasking tool performed assessed patient at 33 hours/week while 42 hours/week. The plan incorrectly assumed that the family could provide informal care outside of the hours that a personal care aide (PCA) is available. The patient has unscheduled and unpredictable care needs that span a continuum of time, and the patient requires at least extensive assistance with walking, locomotion, transfer toilet and toilet use, and the insurer has not documented a plan to meet these unscheduled and unpredictable care needs when the PCA is not present. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). 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 9 hours/day, 5 days/week, and 7 hours/day, 2 days/week to total 59 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.