Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High Blood Pressure
Treatment: Personal Care Aide Level II PCS Level II Basic-15 minutes; 84 hours per week. 12 hours/day, 7 days/week. 
The health plan denied the requested Personal Care Aide Level II PCS Level II Basic-15 minutes; 84 hours per week. 12 hours/day, 7 days/week as not medically necessary.
The health plan's determination is overturned.

The patient is a female with a past medical history of osteoarthritis of the knees, spinal stenosis, chronic rotator cuff injuries, bladder incontinence, compression fracture of (thoracic) T12 vertebrae, dementia, coronary artery disease, hypertension, goiter, myelodysplastic syndrome, atrial fibrillation, bilateral carotid artery stenosis, constipation, and osteopenia who had been assigned personal care aide (PCA) services 49 hours/week based on an assessment performed via video, assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, shopping, transportation, bathing, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With tasks of phone use, personal hygiene, and eating the patient was assessed with extensive assistance while limited assistance with the task of bed mobility. 

The patient's primary care physician (or provider) (PCP) provided a letter stating the patient lived in a private home alone, the family had reported the patient had a decline in functional and cognitive abilities, the patient was only able to ambulate very short distances with a walker, the patient was dependent on others for transfers, the patient was on blood thinners and was at high risk for bleeding if she fell, the family has tried to stay with her overnight, the patient needed assistance with all activities of daily living (ADLs), the patient had lost significant weight over the last year due to not eating and needed help to set up meals and reminders to eat, and the provider was requesting home health aide hours 12 hours/day, 7 days/week so that she may remain safely in the community.

The health plan's determination of medical necessity is overturned, on whole.

There is documentation from the patient's medical providers for the medical necessity of increased PCA services. The patient requires at least maximum assistance with tasks of walking, locomotion, transferring toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time. There is documentation that the patient requires more than extensive assistance with eating and has lost weight over the last year. There is documentation from the patient's medical providers of worsening cognitive impairment and functional ability in the last year. The patient's neurologist also documented the patient's medical condition is progressive and the patient will likely need an increase in support and assistance over time. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with the safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, to a total of 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in her own home.