Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall Risk.
Treatment: Personal care assistance services, 24 hours per day, 7 days per week (Monday though Sunday), a total of 168 hours per week.
The insurer denied personal care assistance services, 24 hours per day, 7 days per week (Monday though Sunday), a total of 168 hours per week.
The determination is overturned.

The patient has a past medical history of osteoarthritis, hearing loss, carpal tunnel syndrome, diabetic neuropathy, diabetes mellitus type 2, dementia, PMR (polymyalgia rheumatica), coronary artery disease (CAD), congestive heart failure, hypertension, hyperlipidemia, and vitamin B12 deficiency who had been signed personal care assistant (PCA) services 40 hours/week. There was a request to increase PCA services.
The patient's primary care physician provided a letter noting the patient's diagnoses and writing to request an increase in home care hours. The letter reported the patient had a decline in her functional status and required assistance with most activities of daily living and all of her Instrumental activities of daily living (IADLs). The letter also stated the patient had several grandchildren who assist her with coordination of care but they did not live nearby and the provider believed the patient required home care assistance both day and night. The provider noted due to the patient's multiple medical problems the patient required increased assistance with transferring, toileting, dressing, meal preparation, and medication administration. The provider also noted that the patient must use the bathroom frequently at night as the furosemide she takes for congestive heart failure causes her to urinate often and the lower extremity edema which is accumulated throughout the day gets reabsorbed when she is laying down at night and causes her to urinate frequently.
The patient underwent an assessment noting the patient to require total assistance with the task of transportation while maximum assistance with the tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping. With the tasks of managing medication, phone use, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility the patient was assessed at extensive assistance while independent with task of eating. The notes from the assessment noted the patient's ADL status had declined over the last 90 days and overall self-sufficiency had deteriorated in the last 90 days.
The insurer sent an initial adverse determination denial notice denying the request to increase PCA services. The patient was hospitalized after being found on the floor by her home health aide when she arrived, the patient was admitted for treatment of a urinary tract infection (UTI). She did undergo multiple imaging tests due to her fall but did not have any fracture. The insurer sent a final adverse determination denial notice denying the request to increase PCA services. The denial stated New York State regulations do not require personal care assistant services for safety supervision alone or for companion care. The denial also stated the patient had no nighttime needs as there was no medical need for frequent nighttime changing of incontinence products, and the patient did not have a decubitus ulcer. The patient saw her home visit provider who noted a need for an increase in custodial care hours. The primary care physician (PCP) appealed the denial decision.
At issue is the medical necessity of personal care assistance services, 24 hours per day, 7 days per week (Monday through Sunday), a total of 168 hours per week.
The services are medically necessary.
The patient's PCP documented a decline in the patient's physical functioning and requested an increase in PCA services specifically requesting overnight services as the patient requires assistance with transfer toilet, toilet use, walking, and locomotion. The provider notes the patient takes Lasix and experiences hemodynamic changes when supine which cause the patient to urinate more. The patient requires at least extensive assistance with the tasks of walking, locomotion, transfer toilet, and toilet use. 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 patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The plan assumed the patient had informal help outside of the hours of PCA services and the patient does not have a family member or support person who can provide informal help outside of the currently assigned PCA hours. 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.