Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis. 
Treatment: Increase in personal care aide (PCA) level 2 services, 8 hours per day 7 days per week for 56 hours per week. 

The insurer denied increase in personal care aide (PCA) level 2 services, 8 hours per day 7 days per week for 56 hours per week. 

The determination is overturned. 

The patient has a past medical history of dementia, urinary incontinence, hypertension, depression, osteoarthritis, and coronary artery disease who had been assigned personal care assistant (PCA) services 4.5 hours/day x 7 days/week to total 31.5 hours/week following an assessment tool performed which assessed the patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of managing finances, managing medication, and shopping. The patient was assessed at extensive assistance with tasks of stairs and transportation while limited assistance with tasks of phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With the tasks of bed mobility and eating, the patient was assessed as independent. 

There was a request to increase PCA services and the patient underwent a telephonic assessment tool  assessing patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, and shopping. The patient was assessed at extensive assistance with phone use, stairs, transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet while limited assistance with tasks of personal hygiene, dressing upper body, toilet use, and bed mobility. With the task of eating the patient was assessed as independent. Notes from the assessment noted that the patient lived with her spouse, had a decline in overall self sufficiency, had progression of osteoarthritis with poor endurance and limited range of motion, needed more assistance with bed mobility, dressing lower body, bathing, walking, transfer toilet and locomotion, needed weightbearing assistance with bathing, needed weightbearing assistance with dressing lower body, needed weightbearing assistance with transfer toilet, needed weightbearing assistance with walking and locomotion, and needed reminders daily to ensure medication compliance. 

The insurer sent an initial adverse determination denial notice denying the request to increase PCA services to 8 hours/day, 7 days/week, to total 56 hours week noting the patient's son had requested an increase in PCA services. The denial notice also stated based on the recent assessment and clinical documentation presented, the current personal care aide services were sufficient to meet her personal care needs. The insurer provided a final adverse determination denial notice continuing to deny the requested increase in PCA services stating it was not medically necessary and the patient did not meet criteria. This denial further stated the son requested an appeal of the denial decision because the patient's spouse was hospitalized, the patient had a decline in cognition, the son was unable to assist with her care, and her current home care hours were not sufficient to meet her personal care needs. The denial further stated the patient's family was supportive and involved in her care, the patient had a shower chair, shower grab bar, walker, and incontinence supplies to assist with her needs, and current personal care needs could continue to be met safely with current PCA service hours. The denial stated additional hours are not provided when tasks are not being performed and for safety monitoring and supervision. 

At issue is the medical necessity of an increase in personal care aide (PCA) level 2 services, 8 hours per day 7 days per week for 56 hours per week. 

The requested services are medically necessary. 
The patient has documented chronic progressive medical conditions of dementia and osteoarthritis. The plan's denial notice stated the patient's spouse was hospitalized, the patient's son reported a decline in patient's cognition, and the patient's son was unable to assist with care needs. The telephonic assessment underestimated the patient's care needs, specifically noting an improvement in her ability to prepare meals compared to her last assessment which is not feasible given patient's worsening functional status. In addition, the patient had an increased need with assistance with tasks of phone use, bathing, dressing lower body, walking, locomotion, transfer toilet, and bed mobility when comparing the telephonic assessment to her prior assessment. This increase in assistance needs specifically with walking, locomotion, and transfer toilet would necessitate an increase in PCA hours. 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 when the patient does not have informal support. The requested increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs)/instrumental activities of daily living (IADLs). The patient's care needs cannot be met with currently assigned PCA hours and/or medical supplies and/or adaptive equipment. 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, personal care aide (PCA) level 2 services, 8 hours per day 7 days per week for 56 hours per week are medically necessary. 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.