Appeal type: Medical necessity
Decision: Overturned

Diagnosis: limited mobility.
Treatment: PCA (personal care aide).
The insurer denied Personal Care Aide (PCA) Level II Basic Service: 112 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of chronic obstructive pulmonary disease (COPD) /asthma, gastroesophageal reflux disease (GERD), colostomy status, osteoporosis, chronic kidney disease, hyperlipidemia, history of pulmonary embolism, and age-related cognitive decline who had been assigned PCA (personal care aide) services. The patient was hospitalized with a COPD exacerbation and there was a request to increase PCA services. The patient underwent an assessment tool assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, shopping, transportation, bathing, and dressing lower body. With tasks of phone use, personal hygiene, dressing upper body, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of equipment management, walking, locomotion, and bed mobility. The patient was assessed as independent with task of eating. Notes from the recent assessment stated the patient was widowed and lived alone. The notes also stated the patient had a second hospitalization for urinary retention and intestinal obstruction. At this assessment, the patient was noted to have generalized weakness with shortness of breath with exertion, ambulated with Rollator walker and 1 person assistance. The patient reported she was unable to transfer on and off a sitting position without assistance, was assisted with transferring to the toilet, and her aide provided toilet hygiene and incontinence cares.

Personal Care Aide (PCA) Level II Basic Service: 112 Hours per Week is medically necessary for this patient.
There is documentation of functional decline of the patient following her 2 recent hospitalizations. The patient's PCP documents medical necessity of increased PCA services. The patient requires extensive assistance with transfer toilet and toilet use as well as limited assistance with walking and locomotion. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The insurer assumed the patient had informal help outside of the currently assigned PCA hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of Instrumental activities of daily living (IADL) and activities of daily living (ADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient also recently had a chronic Foley placed requiring assistance with care related to this device. 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 112 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.