Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Increase in personal care services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week 
The insurer denied an increase in personal care services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week. 
The determination is overturned.

The patient has a past medical history of coronary artery disease, hypertension, diabetes mellitus type 2, hearing loss, anxiety, depression, gastroesophageal reflux disease (GERD), osteoarthritis, migraines, and urinary incontinence who had been assigned personal care assistant (PCA) services 12 hours/day, 7 days/week to total 84 hours/week. There was a request to increase PCA hours and the patient underwent a 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, dressing lower body, walking, locomotion, and toilet use. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, equipment management, personal hygiene, dressing upper body, transfer toilet, bed mobility, and eating. Notes from the assessment stated the patient lives with her husband, was hospitalized in the last month, activities of daily living (ADL) status declined, overall self sufficiency deteriorated, was able to stand and walk very short distances with walker and significant weight bearing assistance, required significant weight bearing assistance with using the toilet, wiping/cleaning, and transferring to/from toilet, required some weight bearing assistance with bed maneuverability, required assistance with eating due to spasms and weakness in her hands, had emergency room (ER) visits and was hospitalized due to hypotension.

The plan sent an initial adverse determination denial notice stating the request to increase PCA services to 24 hours/day, split-shift, 7 days/week was denied because the service was not medically necessary. The denial letter also stated the plan has not identified overnight needs and giving more aide hours cannot prevent all falls or injuries. The denial letter stated the patient may consider splitting hours to better meet her needs and recommended physical therapy. The plan sent a final adverse determination denial notice stating denial of request to increase PCA services also stating the current schedule meets all of her daily activity needs at home and time is not provided for safety supervision, companionship or when tasks are not being done. The patient had a hospital follow up visit stating the patient had been hospitalized due to sepsis/urinary tract infection (UTI). The office note also documented the patient was wheelchair bound and needs 1:1 assistance with all ADLs. The patient was referred to a urologist, was referred to neuro/psychiatrist and stated the patient needed an increase in Home Health Aide (HHA) hours to 24 hours/day for added care and support. The patient's internal medicine office wrote a letter stating the patient had become wheelchair bound and both her mental and physical health have deteriorated significantly. The letter further stated "please consider an increase in her HHA hours to 24 hours/day requiring 2 HHA of 12 hour shifts each." The patient's health care advocate sent a letter of formal external appeal for the plan's denial decision. The letter further stated the  representative submitting the appeal did not provide the appeals department all of the information provided by the patient's representative/designee. The letter further stated the patient cannot wear adult diapers as a primary method for urination as these will cause her to have more urinary infections. The letter further outlined that the patient had a coronavirus infection with a 3 week hospitalization with intubation resulting in functional deterioration. In addition, the health care advocate stated the patient's spouse does not have the physical ability to help the patient and the patient's daughter is a disabled senior citizen and does not have the physical ability to help the patient with her physical necessities. The patient's physician requested an external appeal of the denial decision. At issue is an increase in personal care services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours a week.

The requested services of PCA 24 hours, split-shift, 7 days/week are medically necessary for this patient. The patient has documented progressive medical conditions with multiple hospitalizations over the last year with resultant decline in physical and mental functioning. The patient has ADL needs that are unpredictable and unscheduled and occur outside of the hours the PCA is currently available. The patient does not have informal helpers that are capable to assist her with ADLs/instrumental activities of daily living (IADLs). The increase in PCA hours is not solely for safety and supervision, but to assist the patient with safe completion of ADLs. 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, the requested services 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.