Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Increase in Personal Care Services. 
The denial is overturned. 

The patient is a female with a past medical history of right leg above-the-knee amputation, peripheral vascular disease, recurrent diverticular bleeding, progressive systemic sclerosis, scleroderma, bowel incontinence, bladder incontinence, osteoarthritis, hypothyroidism, hypocalcemia, diabetes mellitus type 2, deep vein thrombosis (DVT), and chronic constipation who had been assigned Personal Care aide (PCA) services 8 hours/day times (x) 5 days/week and Consumer Directed Personal Assistance Program (CDPAP) services 16 hours/week based on telephonic assessment tool performed assessing the patient at total assistance with tasks of ordinary housework and locomotion while maximum assistance with tasks of meal preparation, stairs, shopping, bathing, walking, transfer to toilet, toilet use, and bed mobility. With tasks of managing finances, managing medication, transportation, equipment management, and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of phone use, personal hygiene, and dressing upper body. The patient was assessed as independent with task of eating. The patient's rheumatologist provided a letter stating the patient's medical diagnoses with limited function of hands and arms as well as patient's wheelchair bound status with right leg amputation noting the patient needed around-the-clock care to assist with her activities of daily living (ADL)s. The letter also stated although she lived with her granddaughter, the granddaughter worked outside of the home and could not care for the patient.
The insurer sent final adverse determination denial notice denying request to increase PCA services and recommended splitting current schedule into 2 shifts to meet morning and evening needs and to follow-up with her doctor regarding her medical problems and her treatment options. The denial also stated the plan does not provide time for companionship, safety supervision, or when there are no tasks being done. 
At issue is the medical necessity of Increase in Personal Care Services, 12 hours a day, 5 days a week for a total of 60 hours a week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Increase in Personal Care Services, 12 hours a day, 5 days a week for a total of 60 hours a week is medically necessary for this patient.
The patient's rheumatologist has documented medical necessity of increased PCA services. The patient has assistance needs with walking, locomotion, transferring to the toilet, toilet use and bed mobility. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these care needs. The patient's granddaughter is not able to provide as much informal help as previous. 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 (ADL)s and Instrumental activities of daily living (IADL)s. The patient's medical needs cannot be met with adaptive equipment and medical supplies alone. 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 12 hours/day, 5 days/week, to total 60 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.
Therefore, the requested health service/treatment of Increase in Personal Care Services, 12 hours a day, 5 days a week for a total of 60 hours a week is medically necessary.