Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer.
Treatment: Home Health Care.
The health plan denied the request for an increase in PCA  (personal care assistance)hours. 
The health plan's determination is upheld.

The patient is a female with a past medical history of breast cancer, colon cancer, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), hearing loss, legal blindness, gait instability with use of wheelchair, severe anxiety, urinary incontinence, and osteoporosis who had been assigned PCA (personal care assistance) services 12 hours/day, 7 days/week, to total 84 hours/week. There was a request to increase PCA hours to 24 hours/day, split shift, 7 days/week, to total 168 hours/week. The patient underwent a telephonic assessment tool assessing the patient at total assistance with task of ordinary housework and maximal assistance with tasks of meal preparation, stairs, shopping, and transportation. With tasks of managing medication, bathing, and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of managing finances, phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed as independent with tasks of bed mobility and eating. Then notes from the assessment states the patient requested increased PCA services to assist with diaper changes, using commode at night, and assist with medications because she cannot see. The assessment also noted the patient has no informal helpers. The insurer denied the appeal to increase PCA services. The patient's primary care physician (PCP) provided a letter stating the patient's medical diagnoses, noting the patient is at very high risk for accidents and injuries at home. In addition, the letter stated the patient is non-ambulatory, is unable to transfer to and from her wheelchair without assistance, relies on her home attendant to help her basic needs and activities of daily living such as using the bathroom, bathing, meals, and dressing. The PCP also stated the patient requires 24-hour care in order to ensure her safety further stating if she were to fall in the night while trying to get into the commode or similar situation without assistance, the results could be catastrophic for her. The patient was admitted to the hospital with slurred speech and was diagnosed with a transient ischemic attack (TIA) and was started on a statin and Aspirin. The patient/family and PCP appealed the denial decision.
At issue is the medical necessity of the requested increase in PCA hours.

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

No, the patient does have documented care needs that span 24 hours but there is lack of documentation that the patient has care needs overnight that would not allow an aide 5 hours of uninterrupted sleep. There is not documentation that the patient requires turning and repositioning every 2 hours. The patient is noted to be independent with bed mobility per the assessment tool. Increased PCA hours are not for safety and supervision but to assist the patient with activities of daily living (ADLs) /instrumental activities of daily living (IADLs).