Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis
Treatment: Personal care services, 24 hours a day, 7 days a week (live-in) 
The insurer denied personal care services, 24 hours a day, 7 days a week (live-in).
The determination is overturned.

The patient has a past medical history of rheumatoid arthritis, osteoarthritis, osteoporosis, chronic pain syndrome, frequent falls, insomnia, edema, and urinary incontinence who had a fall while ambulating unassisted, sustaining fractures of the bilateral tibial plateau. The patient had surgery and was transferred to rehabilitation. The patient had a telephonic assessment tool performed while still admitted at rehabilitation facility and was assessed at total assistance with tasks of meal preparation, ordinary housework, stairs, walking, and locomotion while maximal assistance with tasks of shopping, transportation, bathing, dressing lower body, transfer toilet, toilet use, and bed mobility. With the tasks of managing medication, personal hygiene, and dressing upper body the patient was assessed at extensive assistance, while limited assistance with tasks of managing finances and phone use. The patient was assessed as independent with task of eating. The patient was assigned personal care assistant (PCA) services 9 hours/day, 7 days/week to total 63 hours/week following this assessment.

There was a request for an increase in PCA services to 24 hours/day, 7 days/week (live-in). The patient had another telephonic assessment tool performed while still in the rehabilitation facility assessing her at the same level of assistance with all tasks as compared to the prior assessment. The notes from this assessment stated the plan for patient was to be discharged to home and the patient was being transferred via a hoyer lift times (x) 2 to a wheelchair. The physical therapy discharge summary notes from rehabilitation noted that the patient needed stand by assistance with the tasks of rolling and bed mobility while totally dependent with transfers. The patient was not able to ambulate. An occupational therapy discharge summary note from the same day noted the patient at maximal assistance with wheelchair mobility and lower body dressing while total assistance with toileting.

The insurer sent a final adverse determination notice denying the request for an increase in PCA services. The notice stated the patient's current care needs could be met with the current services. In addition, the notice stated time is not provided when there are no tasks being done, recommended using pressure support devices to prevent pressure ulcers, recommended physical therapy upon discharge home, and stated service hours could be split into morning and evening to better meet the patient's care needs. The patient/patient's family appealed the denial decision. The patient's provider appealed the denial decision and provided a letter stating that the patient required hoyer lift with two people for transfers in and out of bed and needs assistance with meals, providing water, turning/repositioning, and administering medication. The letter further states the patient is unable to hold anything in her hands and requires around the clock care and requires 24 hour care to be safely discharged from rehabilitation facility. The patient's healthcare advocate provided a letter summarizing the patient's past medical history and current functional status. In addition, the advocate stated the medical necessity of requested PCA service hours. The letter further stated the patient is bedbound and totally dependent on her aide for ambulation, transfers, toileting, turning and repositioning, and dressing. The advocate also stated the patient's PCA care needs cannot be met with medical supplies and equipment. At issue is the medical necessity of personal care services, 24 hours a day, 7 days a week (live-in).

The requested services are medically necessary. The patient had an injury to the bilateral lower extremities with slow healing and documented decline in functional status. The patient's physical therapy (PT) and occupational therapy (OT) notes document the patient's functional status and needs, specifically totally dependent on aide for transfers and toileting. The patient's provider at the rehabilitation center further stated the medical necessity for 24 hour care. The plan did not take into account unscheduled and unpredictable needs that occur over a particular time span. The patient requires assistance with transfers, toilet use, toileting, and incontinence cares which occur at unscheduled and unpredictable times during the day and night. PCA services are not solely for supervision and safety for this patient but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient does not have an informal helper outside of the currently assigned PCA hours. 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.