Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Down's Syndrome
Treatment: Personal Care Aide (PCA) Services: Live-In, 7 Days per Week (Consumer Direct, 1 Client)
The health plan denied the Personal Care Aide (PCA) Services: Live-In, 7 Days per Week (Consumer Direct, 1 Client). 
The health plan's determination is overturned.

The patient is a male with a past medical history of Down's syndrome, urinary incontinence, bowel incontinence, keratoconus, tremors, obesity, and intellectual disability who had been assigned consumer directed personal assistance program (CDPAP) services 3 hours/day, 7 days/week, to a total 21 hours/week based on assessment performed via video. The patient's medical provider sent a letter stating the patient was born with Down's syndrome with multiple intracardiac abnormalities that required complex surgical corrections as a child and the patient had significant intellectual deficiencies that have become more complicated and limited as new problems have developed. The letter also stated the patient's care requirement had increased considerably so that additional home care hours were urgently medically needed to assist the patient with day-to-day management. Lastly, the letter stated a provider supported the family's request for increased hours. The patient underwent an assessment, in person, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, and shopping while extensive assistance with tasks of stairs, transportation, bathing, dressing lower body, and toilet use. With tasks of equipment management, dressing upper body, and transfer toilet the patient was assessed at limited assistance while supervision with tasks of personal hygiene, bed mobility, and eating. The patient was assessed at independent with tasks of walking and locomotion. Notes from the assessment stated the patient had moderately impaired cognitive skills, was not self-directing, did not have the cognitive ability to call 911, had decline in activities of daily living (ADLs) status over the last 90 days and a deterioration of overall self-sufficiency in the last 90 days. The patient's medical provider sent another letter stating the patient's management of medical issues was complicated by neurologic symptoms resulting in balance abnormalities, frequent falls, urinary and fecal incontinence, tremors, difficulty maintaining effective grasp, and insomnia. The letter also stated the patient required 24-hour live-in assistance for the management of activities of daily living as parental caregiving had been overwhelmed and the patient was scheduled for a full neurologic evaluation in the near future. 
At issue is the medical necessity for the increase in personal care aide service hours.

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

There is documentation of worsening physical and mental functioning from the patient's medical provider. The patient has documented assistance needs with transfer toilet and toilet use; therefore, the patient has unpredictable and unscheduled care needs that span a continuum of time. The requested increase in PCA services is not solely for safety and supervision but can assist the patient with a 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, CDPAP personal care assistant services 24 hours/day, live-in, 7 days/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 his own home.