Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis and metastatic neuroendocrine carcinoma
Treatment: Increase Personal Care (PCA) Services, 12 Hours Per Day - 7 Days Per Week - A Total Of 84 Hours Per Day
The insurer denied the Increase Personal Care (PCA) Services, 12 Hours Per Day - 7 Days Per Week - A Total Of 84 Hours Per Day.
The denial is overturned. 

The patient is a female with osteoarthritis (OA) and metastatic neuroendocrine carcinoma.  The patient is appealing denial of personal care assistant (PCA) services from 84 to 42 hours per week because she is getting weaker.  The patient lives alone.  An assessment performed shows functional status: total dependence with housework; max assistance with meal prep, managing finances and medications, shopping, and transportation; extensive assistance with bathing, personal hygiene, dressing, locomotion, bed mobility, walking and toileting; and independent with phone use and eating.  Compared to assessment performed a couple months prior, there is a decline in personal hygiene, walking and locomotion, which have progressed from limited assistance to extensive assistance.  The patient's son provides daily support.  The patient has a seated rolling walker, shower chair, and incontinent supplies.  The appeal application notes 42 hours per week is insufficient to meet the patient's needs.  It states the patient needs assistance with activities of daily living (ADLs) as accounted for in the most recent assessment.  A statement from the son states the patient's physical strength continues to decline.  She needs more help with transfers and ambulation.  It notes she is a hazard when attempting to prepare meals and has limitation due to lack of physical strength and forgetfulness.  The son states he lives more than one hour away from his mother.  He is also caring for his wife with cancer.  A statement from the doctor states the patient's health has been gradually declining and she is unable to independently perform activities of daily living (ADLs).  It recommends an increase from six to eight based on needs for activities of daily living (ADLs).

Yes, the proposed treatment - Increase Personal Care (PCA) Services, 12 Hours Per Day - 7 Days Per Week - A Total Of 84 Hours Per Day - is medically necessary.

Medically necessary services are those which are:

1) safe 2) effective 3) generally accepted national standard of medical practice 4) not provided primarily for convenience of the patient or the practitioner 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice for this patient.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs), health maintenance activities, and routine support services.  

The assessment shows this patient needs assistance with housework, meal preparation, managing finances and medications, shopping, and transportation, bathing, personal hygiene, dressing, locomotion, bed mobility, walking and toileting.  An assessment performed shows a significant decline in performing personal hygiene, walking and locomotion from the previous assessment.  This decline was accounted for in the most recent assessment performed.  Appeal letters state the patient's physical functioning continues to decline.  The patient is losing strength and requiring more assistance with physical functioning.  The patient has equipment to assist with ambulation and bathing and her son provides informal support.  However, this patient has demonstrated deterioration in physical functioning over a period of several months and is reported by her provider and son to continue declining.  The proposed increase in personal care services (PCS) from 42 to 84 hours is medically the necessary for this patient who has declined in physical functioning to perform housework and provide max assistance with meal preparation, managing finances and medications, shopping, and transportation, bathing, personal hygiene, dressing, locomotion, bed mobility, walking and toileting.