Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty Walking
Treatment: Personal care worker service - 12 hours/6 days a week, totaling 72 hours/week
The insurer denied personal care worker service - 12 hours/6 days a week, totaling 72 hours/week.
The determination is overturned.

The patient has a past medical history of hypertension, hyperlipidemia, glaucoma, coronary artery disease, urinary incontinence, cardiac pacemaker, osteoarthritis, vitamin D deficiency, and age-related hearing loss who had been assigned personal care assistant (PCA) services 7 hours/day, 6 days/week, to total 42 hours/week based on an assessment assessing the patient at total assistance with meal preparation, managing finances, and shopping while maximum assistance with the task of transportation. The patient was assessed at extensive assistance with the task of phone use, stairs, equipment management, bathing, dressing lower body, locomotion, and transfer toilet.

There was a request to increase PCA services and the patient underwent an assessment assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with the tasks of managing finances, managing medication, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The notes from this assessment stated the patient lived with her son, had moderate fatigue, and required a minced food diet.

The insurer sent an initial adverse determination denial notice denying request to increase PCA services stating toileting needs could be met with a bladder training program, durable medical equipment (DME) such as a bedside commode, and/or being toileted before bedtime or upon rising in the morning, the most recent assessment verified the patient was able to transfer adequately to support toileting, the patient did not have predictable/recurring Medical Doctor (MD) appointments scheduled on a weekly basis, so the patient's needs could be met with additional hours added, as needed, for medical appointments, and a warmer bag was ordered for her.

The patient's medical provider sent a letter supporting the need for 72 hours of PCA care and documented the service was medically necessary. The provider noted the patient lived with her son who had been caring for the patient when PCA coverage was not available and the patient's needs had dramatically increased during the last few months and the son could no longer keep up with the pace of her needs the other 126 hours/week. The provider also noted the patient woke up 3-4 times a night to use the toilet and required hands-on assistance which typically took 20 to 60 minutes. In addition, the provider stated the patient had intermittent severe back pain that completely immobilized the patient for several days and the patient will require total hands-on personal care. The provider also stated the patient has urinary urgency and throughout the day requires hands-on assistance to get to and from the bathroom and these needs are unscheduled multiple times during the day. The provider also commented that the patient requires assistance with medication administration, meal preparation, laundry, housekeeping, toileting, bathing, and dressing and the patient's moderate dementia necessitated frequent assistance with tasks, organization, and reminders. The insurer provided a final adverse determination denial notice denying the request to increase PCA services, stating the request was not medically necessary. The patient's medical provider again provided a letter stating PCA services 12 hours/day, 6 days/week are medically necessary for the patient's health and well-being. The patient and her provider appealed the denial decision.

At issue is the medical necessity of personal care worker service - 12 hours/6 days a week, totaling 72 hours/week.

The services are medically necessary. There is documentation of assistance needs with all tasks. The patient has 24-hour care needs and therefore a task-based tool should not have been utilized to calculate PCA hours. The patient requires extensive assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The plan assumed the patient's son could provide informal support outside of the currently assigned PCA services which was incorrect as he was no longer able to keep pace with the patient's needs when PCA was not available. The patient's care needs cannot be met with adaptive equipment and medical supplies or toileting training as the plan indicated. 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, 6 days/week, to total 72 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.