Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD, Osteoporosis.
Treatment: Personal care assistance services, a total of 56 hours per week.
The insurer denied personal care assistance services, a total of 56 hours per week.
The determination is overturned.

The patient has a past medical history of chronic obstructive pulmonary disease (COPD), osteoporosis, gastroesophageal reflux disease (GERD), hyperlipidemia, coronary artery disease, hypertension, and back pain who had been assigned personal care assistant (PCA) services 8 hours/day, 5 days/week, to total 40 hours/week based on a telephonic assessment tool  assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, 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 tasks of bed mobility and eating.
The patient saw her primary care physician (or provider) (PCP) for a follow-up visit with the summary from this visit stating the patient was no longer able to care for herself or home without assistance and her overall medical conditions had progressed and she was now in need of home health aide services. The patient's provider filled out an M11Q form  noting that the patient was becoming forgetful and due to her COPD and heart disease, she was no longer able to do any of her instrumental activities of daily living (IADLs) and was becoming more easily fatigued and needed Home Health Aid (HHA) and housekeeping (HK) services.
The patient's PCP provided a letter noting the patient's medical diagnoses and that patient is prescribed several medications which she must take to maintain her multiple medical conditions which have significant side effects of somnolence, frequency of urination, palpitations, and dizziness. The letter stated due to the patient's medical conditions she had significant fatigue, shortness of breath, and balance issues with a high risk for falling. In addition, the letter stated an increase in PCA services was medically necessary in order to meet all of her personal care needs and required an increase in PCA services to 8 hours/day, 7 days/week. The letter also stated the patient had no family to care for her and had no one to prepare meals for her or go shopping for her.
The patient underwent another assessment assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, and shopping while extensive assistance with the tasks of managing finances, managing medication, stairs, transportation, bathing, and dressing lower body. The patient was assessed at limited assistance with the tasks of phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use. With the tasks of bed mobility and eating the patient was assessed as independent.
The insurer sent an initial adverse determination denial notice denying request to increase PCA services. The insurer sent a final adverse determination denial notice denying request to increase PCA services stating the patient's personal care tasks should be able to be done within the time that had been allotted during the current hours. The denial also stated the patient should call her home care agency and or talk to her care manager about options regarding her schedule that would better fit the patient's needs. The patient's healthcare advocate requested an external appeal of denial decision outlining the patient's past medical history and documents from the patient's PCP and the insurer.
At issue is the medical necessity of personal care assistance services, a total of 56 hours per week. 
The requested services are medically necessary. The patient's primary care provider documented medical necessity of increased PCA services. The patient has unpredictable and unscheduled care needs that span a continuum of time and the patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use. The patient would require PCA services outside of the time that she has informal help. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and 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 56 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.