Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall Risk
Treatment:  personal care worker (PCW) services 7 days per week, 11 hours per day; 77 hours per week
The insurer denied personal care worker (PCW) services 7 days per week, 11 hours per day; 77 hours per week
The determination is overturned.

The patient has a past medical history of osteoarthritis, hypertension, gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH), congestive heart failure, peptic ulcer disease, insomnia, carotid artery stenosis, dementia, coronary artery disease, chronic obstructive pulmonary disease (COPD), lower extremity edema, urinary incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services 8 hours/day, 7 days/week, to total 56 hours/week based on phone assessment performed assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, stairs, shopping, transportation, bathing, dressing upper/lower body, and toilet use. With tasks of managing medication, phone use, equipment management, personal hygiene, walking, locomotion, transfer toilet, and eating the patient was assessed at extensive assistance while limited assistance with task of bed mobility.
There was a request to increase PCA services and the patient underwent a video assessment assessing the patient at total assistance with tasks of ordinary housework, shopping, and equipment management while maximum assistance with tasks of meal preparation, managing finances, phone use, stairs, transportation, bathing, dressing upper/lower body, and toilet use. With tasks of managing medication, personal hygiene, walking, locomotion, transfer toilet, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. The patient's Mini-Mental State Examination (MMSE)  was 11 out of 30. The patient's primary care physician (or provider) (PCP) provided a letter requesting an increase in PCA services as medically necessary and recommended an increase to 24 hours/day, 7 days/week. The letter also stated the patient wakes numerous times during the night and tries to climb out of bed and required changing during the night due to incontinence. Lastly, the letter stated the patient lived alone and had no formal support to provide him with assistance to meet his personal care needs on a regular basis.
The insurer sent an initial adverse determination denial notice denying request to increase PCA services. The denial stated the tasking tool estimated 4.6 hours of PCA services per day and the plan was not required to include safety monitoring as a separate task on the task based assessment form. The plan noted the patient had durable medical equipment (DME) within his home to assist him and recommended the patient continue to receive skilled nursing and physical therapy. The insurer sent a notice of receipt for request of expedited appeal. The insurer sent a letter noting the review of PCA services was being extended.
The insurer sent a final adverse determination denial notice continuing to deny request to increase PCA services. The patient had a home visit noting the patient had periods of forgetfulness and confusion, was not ambulatory, lived in a private apartment, had HHA (Home Health Agency/Aide) hours 7 hours/day, 7 days/week and the rest of the hours were privately paid. The office visit also noted the patient had fallen with a visit to the emergency room. The patient was referred to physical therapy and occupational therapy. The patient's medical provider sent a letter requesting an increase in PCA services as medically necessary. The patient and family appealed denial decision. The patient's son provided a letter appealing the denial to increase PCA services. The letter noted the patient was unable to use his walker since his most recent fall, the patient needed assistance standing up to urinate, the patient could not go to the bathroom without the help of his aide, and the patient's family support was limited. The patient's healthcare advocate provided a letter requesting an increase in home care services stating the final adverse determination notice incorrectly stated the patient could ambulate and transfer with assistance but according to the patient's son, the patient was dependent for toileting and dressing needs. In addition, the letter stated the patient's toileting needs could not be scheduled at specific times so when the aide leaves the patient cannot safely go to the bathroom and take care of his needs on his own. The patient's medical provider appealed the denial decision. At issue is the medical necessity of personal care worker (PCW) services 7 days per week, 11 hours per day; 77 hours per week
The services are medically necessary. There is documentation from the patient's medical provider and son of worsening functional status. The patient's medical provider documented the medical necessity of increased PCA services. The patient has increased assistance needs with tasks of phone use, shopping, equipment management, and bed mobility when comparing the current assessment to his previous assessment. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. 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 (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan incorrectly assumed the patient had informal help for all hours outside of the currently assigned PCA services which was not the case. 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 11 hours/day, 7 days/week, to total 77 hours/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.