Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent Falls
Treatment: Increase in personal care services (PCS) to 24 hours a day, 7 days a week (live-in) temporary
The insurer denied an increase in personal care services (PCS) to 24 hours a day, 7 days a week (live-in) temporary.
The determination is overturned.

The patient has a past medical history of atrial fibrillation, coronary artery disease, congestive heart failure, cognitive impairment, gastroesophageal reflux disease (GERD), chronic kidney disease, chronic hepatitis c, cirrhosis, asthma, osteoarthritis, bladder incontinence, glaucoma, anxiety, and depression who lived with her daughter and had been assigned personal care assistant (PCA) services 5 hours/day, 5 days/week and Consumer Directed Personal Assistance Program (CDPAP) services 5 hours/day, 2 days/week.

The patient had an office visit with her geriatrician noting persistent shortness of breath with minimal exertion, new cirrhosis on imaging, and recurrent falls with ongoing physical therapy (PT)/occupational therapy (OT). The patient had an office visit with a cardiologist noting a complaint of shortness of breath which they felt was related to her asthma. The patient underwent a telephonic assessment due to a report of increased weakness, visual impairment, and change in caregiver availability. The assessment also noted the patient's daughter would be going away. The patient was assessed at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. With the tasks of managing finances, managing medication, stairs, transportation, equipment management, bathing, dressing upper/lower body, walking, locomotion, and transfer toilet the patient was assessed at extensive assistance while limited assistance with tasks of phone use, personal hygiene, toilet use, and eating. The patient was assessed at supervision for task of bed mobility.

The patient's geriatrician provided a letter stating the patient's medical diagnoses, the patient required assistance and prompting when completing her activities of daily living (ADLs), the patient had dyspnea on exertion, the patient required assistance with toileting and was unable to actively participate in her day to day activities. The patient was diagnosed with a urinary tract infection (UTI) and treated with an antibiotic. The insurer provided an initial adverse determination denial notice denying the request to approve PCA services 24 hours/day, live-in, 7 days/week, temporary. The denial stated the patient's daughter did not identify any tasks that are not being met by current schedule, recommended discussing her falls with her medical doctor, stated the patient did not have significant change in her health since the last assessment, recommended a bedside commode to use instead of going to the bathroom, recommended seeing her medical doctor to discuss physical therapy, stated the plan could not authorize services if the member's needs could be met by equipment and supplies, and the plan did not provide an aide for companionship when no tasks were being done. The insurer provided a final adverse determination denial notice denying the request to increase PCA services. At issue is the medical necessity of an increase in personal care services (PCS) to 24 hours a day, 7 days a week (live-in) temporary for a total of 91-168 hours.

The services are medically necessary.

The patient had chronic medical conditions of asthma, osteoarthritis, cognitive impairment, urinary incontinence, and vision impairment requiring at least limited assistance with all ADLs/instrumental activities of daily living (IADLs) except bed mobility. The patient relies on an informal helper outside of the hours she has PCA/CDPAP services. The patient's informal helper will not be available and the insurer assumed the patient has informal/formal help outside of the current PCA/CDPAP service hours. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to address these unpredictable and unscheduled care needs. The patient requires extensive assistance with toilet transfers, but the plan suggested a bedside commode to meet her care needs which does not address her need of assistance with transferring on/off the commode. The plan recommended PT but the patient's medical provider documented she had ongoing PT services. The patient's care needs cannot be met with current PCA/CDPAP hours and/or medical supplies and/or adaptive equipment. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. 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, the requested services 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.