Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Increase in Personal Care Aide (PCA) Level 2 Services for a Total of 68 Hours (9 Hours per Day/5 Days per Week and 11.5 Hours per Day/2 Days per Week) 
The insurer denied the Increase in Personal Care Aide (PCA) Level 2 Services for a Total of 68 Hours (9 Hours per Day/5 Days per Week and 11.5 Hours per Day/2 Days per Week).
The determination is upheld.


The patient has a past medical history of glaucoma, osteoarthritis, oxygen dependent chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, atrial fibrillation, gastroesophageal reflux disease (GERD), hyperlipidemia, hypertension, urinary incontinence, bowel incontinence, breast cancer, anxiety, end stage renal disease on dialysis and had been assigned personal care aide (PCA) service hours at 6 hours/day, 3 days/week, 5 hours/day, 2 days/week and 7 hours/day, 2 days/week based on an assessment tool. The patient was assessed at total assistance for tasks of meal preparation, ordinary housework and shopping while assessed at maximum assistance for task of managing finances. She was assessed at extensive assistance with tasks of stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet and toilet use while limited assistance with tasks of managing medication, personal hygiene, bed mobility and eating. The patient was hospitalized with acute respiratory failure and pneumonia.
There was a request to increase PCA service hours. The patient's primary care physician (PCP) provided a letter stating that the patient's condition has slowly gotten worse with increasing difficulty with physically navigating and accomplishing activities of daily living. The patient had been hospitalized with a significant increase in weakness and deconditioning. Her medical conditions create greater hardships with increasing the need for more home health hours. The patient had a telephonic assessment tool performed which noted increased weakness and fatigue due to end stage kidney disease and dialysis. The patient is short of breath and uses oxygen and walks with a cane making it difficult to carry her oxygen. The patient had a fall when she got tangled in her oxygen tubing. The patient is on Eliquis for atrial fibrillation and Lasix for congestive heart failure. At this assessment, the patient was assessed at total assistance for tasks of meal preparation, ordinary housework and shopping while maximum assistance with tasks of managing finances, stairs, bathing and dressing lower body. The patient was assessed at extensive assistance with tasks of managing medication, transportation, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use and bed mobility while limited assistance with eating. The insurer provided a final adverse determination denial letter stating the request for increase in PCA service hours was not medically necessary as the assessment tool showed many of her abilities to perform physical functioning stayed the same since her prior assessment. At issue is the medical necessity of an increase in Personal Care Aide (PCA) Level 2 Services for a Total of 68 Hours (9 Hours per Day/5 Days per Week and 11.5 Hours per Day/2 Days per Week). 

The requested services are not medically necessary.
The patient's assessment tools did not document a significant change in the patient's functional status for unscheduled tasks of walking, locomotion, transfer toilet, toilet use and bed mobility, which would warrant an increase in PCA service hours. The patient's PCP does not provide verbiage of medical necessity and/or specific reasoning for requested increase in PCA services. There is no documentation of a lack of informal helper for the patient outside of the assigned PCA service hours. There is no documentation of hours of dialysis and need for PCA service assistance during those hours. There is documentation that the patient fell but no documentation if this was when patient was alone or during PCA service hours. There is no documentation provided by the PCP or the patient's current PCA attendant or family that the patient's  telephonic assessment underestimated her PCA care needs.