Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive supranuclear ophthalmoplegia
Treatment: Personal care aide (PCA) Level 2: 12 hours per day/7 days per week, 12 hours per day/7 days per week (split shift), for total of 168 hours per week
The insurer denied the personal care aide (PCA) Level 2: 12 hours per day/7 days per week, 12 hours per day/7 days per week (split shift), for total of 168 hours per week.
The determination is overturned.

The patient has a past medical history of progressive supranuclear ophthalmoplegia, bladder incontinence, bowel incontinence, atrial fibrillation, hypertrophic obstructive cardiomyopathy, coronary artery disease, hypertension, emphysema, and diabetes mellitus type 2. He had a request for 24 hour aide services. An office note from his neurologist stated that the patient currently had personal care aide (PCA) services for 8 hours/day, but requested an increase to 24 hours/day and the provider documented writing a letter to increase the PCA hours. A neurology office note documented severely impaired leg agility and inability to rise from a chair without help, as well as severe gait disturbance requiring assistance and unstable posture. The patient was on anticoagulant medication for atrial fibrillation.

The patient had a telephonic assessment tool performed, assessing the patient at total assistance with all tasks except bed mobility, for which he was assessed at maximum assistance. The patient underwent another telephonic assessment tool, with the same results. Notes from the most recent assessment stated that the patient lived with his wife, had severely impaired cognitive status, was unable to answer questions due to aphasia, was pushed in a wheelchair for mobility, and had to be hand fed pureed food.

The insurer a sent final adverse determination denial notice (FADDN) denying the request to increase PCA services, stating it was not medically necessary and the patient did not meet criteria. The denial letter stated that most of the patient's abilities to perform physical functioning were at limited assistance and therefore, the patient's hours would stay at 9.5 hours/day, 7 days/week, to total 66.5 hours/week. In addition, the denial stated that additional hours are not provided for supervision, companionship, or when tasks are not being performed by the aide. The patient had a telemedicine neurology follow up appointment, with the office note documenting that the patient spent the year in Pakistan, but was back home. Walking/balance were progressively worse and he was mostly using a wheelchair. The office note stated that the patient had severe unintelligible dysarthria and significant drooling. Overnight logs were provided, noting assistance with bed mobility, turning and positioning, and incontinence cares at least every 2.5 hours. The patient's neurologist provided a letter stating that the patient needs assistance with all activities of daily living (ADLs), was wheelchair bound, was severely dysarthric, and could not change his position in bed by himself. The letter also stated that the patient's brother who provided overnight care would not be able to continue to provide care, due to his own worsening medical conditions. The letter also stated it was medically necessary for the patient to have around the clock care, 7 days/week for safety reasons, due to his progressively declining condition. The patient's healthcare advocate provided a letter requesting an external appeal of the plan's denial decision. The letter outlined the background information and conclusion of why it was medically necessary for the patient to have an increase in PCA hours. At issue is the medical necessity of PCA Level 2: 12 hours per day/7 days per week, 12 hours per day/7 days per week (split shift), for total of 168 hours per week.

The services are medically necessary.

The patient has documented progression of his chronic medical condition of progressive supranuclear palsy/ophthalmoplegia. The patient's medical provider has documented the medical necessity for increased PCA hours, specifically to 24 hours/day, split-shift. The patient has unscheduled and unpredictable care needs of repositioning, toileting, transfer toilet, and incontinence care and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The patient's informal caregiver is no longer able to provide the current level of care and the patient requires at least maximum assistance with all ADLs/instrumental activities of daily living (IADLs). In the FADDN, the plan stated that most of the patient's abilities to perform physical functioning were at limited assistance, however, the assessment documented total assistance for all tasks except bed mobility. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 24 hours/day, split-shift, 7days/week, to total 168 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.