Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Personal Care Assistance (PCA) services, 12 hours/day, 7 days/week, for a total of 84 hours/week
The insurer denied PCA services, 12 hours/day, 7 days/week, for a total of 84 hours/week.
The determination is overturned.

This is a patient with a past medical history of legal blindness, anxiety, depression, urinary incontinence, osteoarthritis, chronic pain, dizziness, and mild intellectual disabilities who had been assigned personal care assistant (PCA) services 49 hours/week based on an assessment tool assessing the patient at total assistance with task of ordinary housework, managing finances, managing medication, phone use, shopping, and equipment management while maximum assistance with tasks of meal preparation, transportation, and bathing. With the tasks of stairs, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with task of eating. The patient was assessed at supervision only with task of bed mobility. Notes from the assessment stated the patient had moderately impaired cognitive skills, had history of multiple falls, and relied on a walker and wheelchair for locomotion.

There was a request to increase PCA services and the patient underwent another assessment tool, assessing the patient at total assistance with the tasks of ordinary housework, managing finances, managing medication, phone use, shopping, and equipment management while maximum assistance with task of meal preparation. With the tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and eating the patient was assessed at extensive assistance while supervision with task of bed mobility. Notes from the assessment stated the patient had a decline in activities of daily living (ADLs) status and a deterioration in overall self-sufficiency and had suffered a fall in the last 90 days with fracture of the spine.

The insurer sent a final adverse determination denial notice stating the request to increase PCA services to 12 hours/day, 7 days/week, to total 84 hours/week was not medically necessary and the hours given under the last authorization or reauthorization were still enough to meet the patient's needs. The denial also stated New York State regulations do not require PCA services for safety supervision alone without the need for activity of daily living tasks. The denial also stated cognitive prompting is not a specific stand-alone task required to be performed by a PCA. In addition, the denial stated the patient's care manager had arranged for skilled nursing needs including approved time for physical therapy and that the patient should continue to keep all follow-up appointments with the patient's medical providers. The patient and family appealed the denial decision with a description of services by the patient and family noting the patient stopped going to a daily adult program and received 4 extra hours of PCA services daily but those 4 extra hours of services were taken away.

At issue is the medical necessity of PCA services, 12 hours/day, 7 days/week, for a total of 84 hours/week.

Yes, the services are medically necessary.

When comparing the assessments, there was documented improvement with the tasks of transportation, bathing, and eating. The other tasks remained the same. The patient, however, had been attending adult daycare for 4 hours/day receiving assistance with ADLs and instrumental activities of daily living (IADLs) but the services ended and had not been reinstituted. The patient therefore had at least 4 hours of additional ADLs and IADLs assistance needs. The plan took these hours away despite the patient not returning to adult daycare. There is documentation from the plan's assessment that the patient had a decline in ADLs status and deterioration of overall self-sufficiency compared to prior assessment despite noting improvement in some of the ADLs and IADLs needs. Therefore, the assessment underestimated the patient's care needs. The patient is legally blind and is unable to perform any ADLs without assistance. The patient would need PCA support during the hours which they did not have informal support. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not for safety and supervision alone, but to assist the patient with safe completion of ADLs and IADLs. 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, 7 days/week, to total 84 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 their own home.