Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Frequent Falls. 
Treatment: Home Health Care. 

The insurer denied Personal Care Aide (PCA) Level 2 Services: 47 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, osteoarthritis, dementia, glaucoma with vision loss in the right eye and legal blindness in the left eye, urinary incontinence, and bilateral hip fractures with repair who had been assigned PCA (personal care aide) services based on the assessment tool assessing the patient at total assistance with task of managing finances while maximum assistance with tasks of meal preparation, ordinary housework, managing medication, phone use, shopping, and equipment management. With tasks of stairs, transportation, bathing, and transfer toilet, the patient was assessed at extensive assistance while limited assistance with tasks of dressing upper/lower body, and toilet use. The patient was assessed at supervision with tasks of personal hygiene, bed mobility, and eating. The patient had a fall at home recently. There was a request to increase PCA services and the patient underwent another assessment tool assessing the patient at total assistance with tasks of ordinary housework and managing finances while maximum assistance with tasks of meal preparation, managing medication, phone use, and shopping. With tasks of stairs, transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet, the patient was assessed at extensive assistance while limited assistance with tasks of dressing upper body and toilet use. 

Personal Care Aide (PCA) Level 2 Services: 47 Hours per Week are medically necessary for this patient. 

There is documentation by the patient's PCP and the recent assessment of decline of the patient's physical and cognitive functioning. The patient requires at least limited assistance with toilet use, transfer toilet, walking, and locomotion. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The plan made the assumption that the patient had informal help outside of the hours she has PCA services or social daycare. The patient's son is no longer able to provide the same level of informal help due to his own medical condition and with recurrent of cancer and need for chemotherapy. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with medical supplies and adaptive equipment. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide (PCA) Level 2 Services: 47 Hours per 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 her own home.