Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal - Osteoarthritis.
Treatment: Home Health Care/ Personal Care Aide (PCA): Live-In Per Diem: 24 hours per day - 1 day(s) - 7 day(s) per week - a total of 7 days per week.
The insurer denied Personal Care Aide: Live-In Per Diem: 24 hours per day - 1 day(s) - 7 day(s) per week - a total of 7 days per week.
The denial is overturned.

This patient is a female with a past medical history notable for coronary artery disease, chronic back pain, osteoarthritis, history of several recent falls with associated fractures and pain, atrial fibrillation, and hypertension. She currently receives 6 hours per day, 7 days per week (total of 42 hours per week) of Personal Care Aide (PCA) services. Her care team requested an increase in services to 24-hours live-in assistance.
A letter of appeal was submitted on the patient's behalf by an advocate. The letter outlines the concern that the patient is known to require assistance with toileting, however, the plan is only covering that assistance for 6 hours per day. The patient needs help with toilet transfers, hygiene, and redressing after toileting. A letter of support was provided by the patient's internist. This letter states that the patient "needs more assistance."
The patient's son wrote a letter of support on her behalf. In it, he states that the patient has "serious physical challenges to her activities of daily living." She ambulates with a walker but requires assistance to transfer. She has had falls related to transfers without assistance. She uses the bathroom throughout the night, and he reports that she needs assistance with this. She is currently continent of urine and stool.
A Uniform Assessment System (UAS) was completed and was available for review. Cognition was found to be intact with modified independence. She requires maximal assistance for meal preparation, total dependence on housework, and extensive assistance in managing medications. The patient requires maximal assistance for dressing the upper and lower body, as well as bathing. She requires extensive assistance for personal hygiene, toilet use, toilet transfer, walking, and locomotion. The patient was observed ambulating with a rollator walker and reported "needing some weight bearing assistance with walking." She is noted to be infrequently incontinent of urine, with no episodes in the prior three days. She is continent of stool. She was noted to have an open wound on the lateral right leg and followed with wound care.
At issue is the medical necessity Personal Care Aide (PCA): Live-In Per Diem: 24 hours per day - 1 day(s) - 7 day(s) per week - a total of 7 days per week.

The health plan's determination of medical necessity is overturned as a whole.

No, the requested health service/treatment of Personal Care Aide (PCA): Live-In Per Diem: 24 hours per day - 1 day(s) - 7 days (s) per week - a total of 7 days per week is medically necessary for this patient.
The patient needs help with any type of ambulation and toileting, and it is not reasonable to expect these activities to occur in an isolated six-hour block every day. She has already had several falls related to attempting activities independently, which according to the UAS she is not functionally capable of doing. She requires ongoing assistance throughout the day and periodically during the night. Failure to provide this assistance would not be meeting the patient's basic needs for support in activities of daily living. Adverse medical outcomes could be expected as a reasonable consequence if she is unable to get this assistance.
Therefore, the requested health service/treatment of Personal Care Aide (PCA): Live-In Per Diem: 24 hours per day - 1 day(s) - 7 days (s) per week - a total of 7 days per week is medically necessary.