Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty in Walking, Functional Urinary Incontinence, Fecal Urgency, Heart Failure, Insomnia, Lymphedema, Other Chronic Pain, Other Fatigue, Other Obesity, Primary Generalized Osteoarthritis
Treatment: Personal Care Aide Services: 5 Days per Week, 12 Hours per Day (60 Hours) + 2 Days per Week, 4 Hours per Day (8 Hours) - Total 68 Hours per Week
The insurer denied the personal care aide services. The health plan's determination is overturned.

The patient is an elderly female with multiple comorbidities who had been assigned personal care aide (PCA) services 9 hours per day, 5 days per week based on an assessment performed via video. Notes from the assessment stated the patient lived with her daughter.

The patient was later hospitalized for a myocardial infarction. There was a request to increase her PCA services, and she underwent another video assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, and locomotion while maximum assistance with tasks of managing finances, transportation, bathing, dressing lower body, transfer toilet, and toilet use. With tasks of managing medication, phone use, equipment management, personal hygiene, dressing upper body, and bed mobility she was assessed at extensive assistance while supervised with task of eating. It was noted she did not perform the activity of walking and was noted to utilize a wheelchair or scooter for ambulation. Notes from the second assessment stated the patient's daughter worked 11 to 12 hours per day during the week and a few hours on Saturdays. The patient's medical provider sent a letter on behalf of the patient stating it had been deemed medically necessary for her to receive home health aide services 5 days per week, 12 hours per day, and 4 hours per day, 2 days per week, to total 68 hours per week as the patient required assistance with all activities of daily living (ADL).

At issue is the medical necessity for Personal Care Aide Services: 5 Days per Week, 12 Hours per Day (60 Hours) + 2 Days per Week, 4 Hours per Day (8 Hours) - Total 68 Hours per Week.
I overturn the health plan's determination, in whole.

The requested personal care aide services are medically necessary.

There is documentation from the patient's medical provider supporting the medical necessity of increased PCA services. There is documentation from the plan's own assessment of increased assistance needs with tasks of meal preparation, managing finances, shopping, bathing, walking, locomotion, transfer toilet, and bed mobility. The plan assumed the patient had informal help outside of the currently assigned PCA service hours which was not the case, as the patient's daughter, who is her informal support, works 12 hours per day and 8 hours on the weekend. The patient requires at least maximum assistance with walking, locomotion, transfer toilet, and toilet use, and therefore, has unpredictable and unscheduled care needs that span a continuum of time. The insurer failed to document a plan to meet these unpredictable and unscheduled care needs during the time she does not have PCA services. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's care needs will not be met even with improved functional mobility with physical therapy and occupational therapy. 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 5 Days per Week, 12 Hours per Day (60 Hours) + 2 Days per Week, 4 Hours per Day (8 Hours) - Total 68 Hours per Week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in her own home.