Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acquired absence of left upper limb above elbow, cellulitis of left lower limb, dependence on wheelchair.
Treatment: personal care assistance 24 hours per day 7 days per week (split-shifts); a total of 168 hours per week.
The insurer denied personal care assistance 24 hours per day 7 days per week (split-shifts); a total of 168 hours per week.
The determination is overturned.

The patient has a past medical history of peripheral vascular disease, osteoarthritis, diabetes mellitus type 2, wheelchair dependence, cerebral vascular disease, hyperlipidemia, and hypertension, who had been assigned personal care assistant (PCA) services three hours per day, seven days per week, to total 21 hours per week based on an assessment performed telephonically assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, and shopping with extensive assistance with the tasks of transportation, stairs, bathing, and dressing lower body. With the tasks of managing finances, managing medication, phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use, the patient was assessed at limited assistance while independent with the tasks of bed mobility and eating.
The patient was admitted to a rehabilitation facility and subsequently admitted to the hospital for a left below the knee amputation related to complications of peripheral vascular disease (PVD). The patient was discharged back to the rehabilitation facility but readmitted to the hospital with cellulitis and underwent a left above the knee amputation. The patient started receiving physical therapy (PT) and occupational therapy (OT). There was plan for discharge to home but as part of the discharge process an increase in PCA services was requested and the patient underwent an assessment tool assessing the patient at total assistance with the tasks of ordinary housework and stairs while maximum assistance with tasks of meal preparation, transportation, shopping, bathing, dressing lower body, locomotion, transfer toilet, and toilet use. The patient was assessed at extensive assistance with the tasks of managing finances, managing medication, equipment management, personal hygiene, dressing upper extremity, and bed mobility while limited assistance with tasks of phone use and supervision with task of eating.
The insurer provided a coverage determination notice denying the request to increase PCA hours. The denial stated that the patient required 2 person assistance for Hoyer lift transfers from bed to chair and the patient had a sacral wound and a right heel ulcer that needed daily and as needed dressing changes. In addition, the denial notice stated the nursing assessment indicated the patient was incontinent of bowel and bladder. Lastly, the denial stated the patient did not have consistent informal support to assist with her skilled care needs and two person assist needs and the patient's care needs could not be met by a PCA in the home.
The insurer sent an appeal decision notice continuing to deny the request to increase PCA services. The patient's primary care physician (PCP) provided a letter stating he had been the patient's doctor for over 20 years and the patient was suffering from post-amputation complications and consequent physical and emotional disability and was homebound and bedbound and required homecare throughout the day and night. The letter also noted the patient required ambulating, toileting, transferring, and turning/repositioning at unscheduled times throughout the day and night such that a PCA would not be able to sleep 5 consecutive hours. A provider from rehabilitation provided a letter stating the patient's diagnoses and due to her medical condition the patient needed an aide to assist her with ambulation, toileting and turning and repositioning at unscheduled times.
The patient's daughter provided a letter stating the patient did not have informal care at home prior to her recent hospitalizations and the patient's wishes were to come home with 24 hour split-shift care. The daughter's letter also stated he did not have the capacity to care for the patient because of other responsibilities but he was able and willing to direct her care if necessary. The patient's health care advocate provided a letter requesting external appeal of denial decision stating it was improper for the plan to deny a request for PCA services on the reasoning that a nursing home is a "better setting", without first assessing whether a different service could meet the patient's needs, such as private duty nursing, should the patient want to go home. The letter also stated the patient's need for 2-person assistance for a Hoyer lift, if accurate, should not pose an obstacle to the patient's intent to return home as the insurer needs to authorize services that "reflect the enrollee's ongoing need for such services and supports".
At issue is the medical necessity of personal care assistance 24 hours per day 7 days per week (split-shifts); a total of 168 hours per week.
The services are medically necessary.
The patient has a documented change in functional status following above the knee amputation. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet the patient's unscheduled and unpredictable care needs. The patient requires turning and repositioning due to sacral ulcer and heel ulcer. The patient's overnight care logs including turning/repositioning and attending to unpredictable and unscheduled care needs would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The insurer cannot deny a request for PCA services on the reasoning that a nursing home is a "better setting", without first assessing whether a different service could meet the patient's needs, such as private duty nursing, should the patient want to go home. The patient's need for 2-person assistance for Hoyer lift, if accurate, should not pose an obstacle to the patient's intent to return home as the insurer needs to authorize services that reflect the enrollee's ongoing need for such services and supports. 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, 7 days/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 her own home.