Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CVA, Diabetes 
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week
The determination is overturned.

The patient has a past medical history of a cerebrovascular accident (CVA) with left hemiplegia, diabetes mellitus type 2, colon cancer, status post transcatheter aortic valve replacement (TVAR), hearing loss, hyperlipidemia, bladder incontinence and bowel incontinence who had been assigned personal care assistant (PCA) services 7 hours/day, 7 days/week, to total 49 hours/week based on a telephonic assessment tool assessed the patient at total assistance with the tasks of meal preparation, ordinary housework, shopping, and locomotion while maximum assistance with tasks of managing finances, managing medication, stairs, transportation, bathing, dressing lower body, transfer toilet, and toilet use. With the tasks of personal hygiene, dressing upper body, and bed mobility the patient was assessed at extensive assistance while set up only with task of phone use. For the task of walking, it was noted that activity did not occur.
The patient's primary care physician (PCP) provided a letter noting the patient lived with his medically frail spouse in an apartment and his spouse had been in a motor vehicle accident and was unable to assist with the patient's care. The letter noted the patient's family was paying privately for aide services 5 hours/day. The letter also noted the patient was high risk for falls because of his mobility challenges and had multiple falls, most recently when his spouse had tried to transfer him. In addition, the provider letter stated the patient was incontinent of bowel and bladder, his caregiver turned and repositioned him every 2 hours in bed and every hour in the chair during the day and he has been free from skin breakdown and beds sores. The provider stated the patient needed to have a diaper change as soon as it was soiled and the patient also needed assistance with repositioning as he was dependent on bed mobility. Lastly, the letter requested 12 hours of care so the patient could remain safe in his home.
The patient underwent an assessment tool telephonically assessing the patient at total assistance with tasks of ordinary housework, stairs, transportation, and locomotion while maximum assistance with tasks of meal preparation, managing finances, managing medication, shopping, bathing, dressing lower body, transfer toilet, toilet use, and bed mobility. The patient was assessed at extensive assistance with task of personal hygiene, while limited assistance with task of eating and set up only with phone use. The task of walking did not occur.
Notes from the assessment stated the patient had a deterioration in overall self-sufficiency but no change in activities of daily living (ADL) status compared to 90 days ago. The assessment also stated the patient slept on his back and the PCA supported him on his left side to turn and reposition in bed and needed weightbearing support to move in bed.
The insurer sent an initial adverse determination denial notice denying the request to increase PCA services to 12 hours/day, 7 days/week split shift to total 168 hours a week. The denial stated the patient could transfer on and off the toilet and take care of his toileting needs with assistance, required safety monitoring and supervision as a stand-alone task, and that current level of PCA services were appropriately and safely meeting his personal care needs.
The physician and patient appealed denial decision. The insurer sent a final adverse determination denial notice stating patient did not meet criteria and hours stayed the same at 7 hours/day, 7 days/week, to total 49 hours/week. The denial also stated additional hours were not provided for stand-alone safety supervision, companionship, or when the aide is not performing tasks. The patient's daughter provided a request for appeal noting the patient continued to have functional decline and required hands-on care 24 hours/day, 7 days/week but the family was willing to care for him during the night hours and were requesting 12 hours/day so he could remain safe in his home.
The patient's primary care physician (PCP) appealed the denial decision. The patient's daughter provided a letter, undated, requesting an appeal for additional healthcare aid hours for her father. The letter noted the patient cannot roll over in bed or adjust himself when seated or lying down. The daughter's letter also stated his family members were not capable to care for him and did not have the financial means, physical ability, or time to commit to his proper care. In addition, the daughter noted the hospital discharge papers from his cerebrovascular accident (CVA)noted the patient needed to use a wheelchair at all times, needed the help of 2 people if taking steps with a hemiwalker, needed somebody else to prepare all meals, needed to have all of his food cut up and ready and bite-size pieces, needed physical help for the commode and shower and all basic personal care. The daughter also noted the current hours confined him to a bed for 17 hours a day and he has had issues with diaper rash and back pain related to prolonged periods of being in bed.
At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week.
There is documentation from both assessments of significant assistance needs with all activities of daily living (ADLs) including transfer toilet, toilet use, bed mobility and locomotion. The patient has 24 hour care needs and task based tool should not have been used to calculate PCA hours. The patient's primary care provider documented the patient required turning and repositioning every 2 hours overnight and prompt changing of soiled undergarments to prevent skin breakdown and bedsores. This need for turning and repositioning and changing of soiled undergarments would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's family is no longer able to financially afford to private pay for additional services. The patient's family is no longer able to provide informal help according to the daughter's letter. 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, PCA services 12 hours/day, 7 days/week; 12 hours/day, 7 days/week (split-shift) to total 168 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 his own home.