Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in PCA hours. 
The denial is overturned in whole.

The patient is a female with a past medical history of dementia, hypertension, atrial fibrillation, spinal stenosis, osteoarthritis, urinary incontinence, and coronary artery disease who had been assigned personal care assistance (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week.
The patient's primary care physician (or provider) (PCP) provided a letter stating the patient was unable to perform activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s and it was medically necessary for the patient to receive a home health aide for 24 hours/day. The patient's son provided a letter stating the denial report from insurer incorrectly stated the patient's granddaughter lived with the patient (she lived across the street). The granddaughter had been sleeping at the patient's house since when the patient's husband passed. The patient's son would sleep overnights on the weekends. The son's letter also stated the patient gets up 2-3 times at night to use the bathroom and other times to attempt to bathe herself or enter the kitchen to cook a meal. In addition, the letter from the son stated the patient sometimes would leave the stove on, leave the refrigerator door open and bathroom faucets left open. Lastly, the letter from the son stated a Department of Social Services (DSS) case worker and the nurse who did the assessment recommended the patient receive PCA services 24 hours/day but the son asked if they could start with 12 hours/day, 7 days/week to start to get the patient comfortable with having an aide in her home, which they agreed with and stated the son could then request 24 hours/day, 7 days/week.
At issue is an increase in Personal Case Assistance services 2-12-hour split shifts per day, 7 days per week (Monday through Sunday), a total of 168 hours per week.

The health plan's determination is overturned in whole.

The requested health service/treatment of increase in Personal Case Assistance services 2-12-hour split shifts per day, 7 days per week (Monday through Sunday), a total of 168 hours per week is medically necessary for this patient.
The patient has documented functional and cognitive decline. The patient requires at least limited assistance with all ADLs and IADLs. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient has 24-hour care needs, and the plan incorrectly utilized the assessment tool to calculate PCA hours. The patient has overnight care needs to assist with going to the bathroom, personal care, walking, locomotion, as well as bed mobility, and transferring to the toilet. There is documentation that the patient is up three times at night to urinate which would not allow a personal care aide 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 and IADLs. 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 o 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.
Therefore, the requested health service/treatment of increase in Personal Case Assistance services 2-12-hour split shifts per day, 7 days per week (Monday through Sunday), a total of 168 hours per week is medically necessary.