Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis. 
Treatment: Personal Care Aide (PCA) Services: Total of 70 Hours per Week (10 Hours per Day / 7 Days per Week). 

The insurer denied Personal Care Aide (PCA) Services: Total of 70 Hours per Week (10 Hours per Day / 7 Days per Week). 

The health plan's determination is overturned. 

The patient is a female with past medical history of age-related cognitive decline, osteoarthritis, bladder incontinence, chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, hyperlipidemia, coronary artery disease, and history of breast cancer with upper extremity lymphedema. She had been assigned personal care aide (PCA) services 5.5 hours/day, 7 days/week, to total 38.5 hours/week based on assessment that was performed. The patient was assessed at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, shopping, transportation, bathing, and dressing upper body. With tasks of phone use, personal hygiene, dressing lower body, walking, locomotion, toilet transfers, toilet use, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. The tasking tool estimated 42 hours/week. 

There was a request to increase PCA services and the patient underwent another assessment assessing the patient at the same level with tasks when compared to another assessment except for the task of dressing lower body which changed from extensive assistance to maximum assistance. The tasking tool estimated 42 hours/week. Notes from the assessment stated the patient lived alone, had a decline in her activities of daily living (ADL) status over the last 90 days, and had a deterioration of overall self-sufficiency in the last 90 days. The patient's medical provider appealed denial decision. The patient appealed denial decision. On the same date, the patient's healthcare advocate provided a letter requesting external appeal of denial decision outlining the patient's medical history as well as information regarding the patient's case with documentation of correspondence from the patient, the patient's medical provider, and the plan's assessments. In addition, the healthcare advocate noted the patient reported that she had medications that needed to be taken in the evening and the patient needed reminders with this.

There is documentation from the patient's medical provider as noted in the healthcare advocate letter of medical necessity of increased PCA services. There is documentation from the plan's own assessment that the patient requires at least extensive assistance with tasks of walking, locomotion, toilet transfers, and toilet use all of which are unscheduled and unpredictable care needs that span a continuum of time.
The insurer has not documented a plan to meet these unscheduled and unpredictable care needs when the patient does not have PCA services or informal help. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's care needs are not solely for safety and supervision but to assist the patient with Activities of Daily Living (ADL)'s and instrumental activities of daily living (IADL)'s. The patient's current PCA service hours cannot be split to meet morning and evening needs as the patient has unpredictable and unscheduled care needs. 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 10 hours/day, 7 days/week, to total 70 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. 
The health plan's determination of medical necessity is overturned in whole.