Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Home Health Care. 

The insurer denied personal care aide (PCA) level 2: 12 hours per day 7 days a week for a total of 168 hours per week. 

The denial is overturned. 

The patient is a 74-year-old female with past medical history of diabetes mellitus type 2, dementia, schizophrenia, overactive bladder, anemia, history of uterine cancer status post radiation, coronary artery disease, cirrhosis with ascites, depression, radiation proctitis, incontinence of bowel and bladder, and need for recurrent transfusion due to recurrent gastrointestinal (GI) bleeding who had been assigned personal care aide (PCA) services 6 hours/day, 7 days/week, based on assessment tool performed assessing the patient at total assistance with tasks of ordinary housework and shopping while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, transportation, and bathing. The patient was assessed at extensive assistance with tasks of phone use, dressing lower body, walking, locomotion, transfer toilet, and toilet use while limited assistance with tasks of personal hygiene and dressing upper body. With tasks of bed mobility and eating the patient was assessed at independent. The patient's psychiatrist provided a letter noting the patient's diagnoses and stating the patient had poor coordination and high risk for falling and due to the severity of her mental and medical problems it was urgent to provide the patient with 12 x 12 (split shift)/7 days/week of home care services. 

The insurer provided final adverse determination denial notice denying request to increase PCA services stating it was not medically necessary and granting additional hours was not provided when tasks were not being performed and for safety monitoring and supervision. An office visit with the patient's primary care provider noted the patient was receiving a transfusion every 3 weeks and was refusing bariatric treatment that have been recommended to treat her radiation proctitis bleeding. There was another office visit note again noting the patient was receiving blood transfusions and iron treatment frequently and spent 80% of her time in bed. The patient's legal advocate requested an expedited external appeal of denial decision by insurer. 

Personal Care Aide (PCA) Level 2: 12 hrs. per day - 7 days per week; 12 hrs. per day - 7 days per week for a total of 168 hours per week is medically necessary for this patient. 
There is documentation that the patient had significant decline in physical and mental functional capacity following her prolonged hospitalization. Notes from a visiting nurse assessment noted the patient was totally dependent with toileting. Furthermore, the telephonic assessment underestimated the patient's assistance needs with ADLs. Overnight care logs indicate the patient requires assistance with activities of daily living (ADLs) throughout the night to such an extent that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The patient has unscheduled and unpredictable care needs that span a continuum of time.  The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs).
Taking into account clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services 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.