Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease-Viral Infection-Post COVID 19 fatigue
Treatment: Home Health Care-PCA
The health plan denied the increase in PCA services as not medically necessary. The reviewer overturns the health plan denial in whole.

The patient is elderly with a past medical history of vascular dementia, coronary artery disease, congestive heart failure, cerebrovascular accident with gait instability, chronic kidney disease stage 4, urinary retention with recurrent urinary tract infection, lumbar degenerative disc disease, chronic pain, osteoarthritis of the knees, chronic edema and urinary incontinence who had been assigned personal care assistant (PCA) services 8 hours/day, 7 days/week to total 56 hours/week. The patient was hospitalized with coronavirus disease 2019 (COVID 19) infection with subsequent rehabilitation stay and further hospitalizations two times for complications of urinary retention. There was a request to increase PCA service hours following his hospitalization and rehabilitation stay for COVID 19. This provider recommended PCA services 24 hours/day, 7 days/week in order to be safely discharged and remain in the community. The patient had a universal assessment tool performed telephonically and assessed the patient at total assistance for tasks of ordinary housework and transportation while maximum assistance with tasks of meal preparation, stairs, shopping, bathing, dressing of upper and lower body and locomotion. The patient was assessed at extensive assistance for tasks of managing medication, personal hygiene, walking, transfer toilet and toilet use while limited assistance with tasks of phone use, bed mobility and eating. This assessment noted the patient ambulates with a walker, the patient's diaper is soaked in the morning when the aide arrives, the patient fell off the bed twice while in rehabilitation, and does not have an informal helper. The patient was hospitalized again. The patient's hospital provider provided a letter stating the patient would be discharged with a urinary catheter, is high risk for falls due to unsafe transfers and ambulation without the assistance of one person and it was recommended that the patient have an increase in PCA services hours to 24 hours/day, 7 days/week. The patient's PCP provided a letter of medical necessity for increase in home care hours. This letter also stated "Due to his rapid cognitive, physical, and functional decline, along with his visual and hearing sensorial loss, The patient is unable to carryout normal activities of daily living independently, and is completely dependent on his home health aide's assistance, to do so. For this reason, he needs continuous supervision and assistance during the day and nighttime. He can no longer perform activities of daily living, such as cooking, cleaning, bathing, dressing, grocery shopping and maintaining his household. 

The patient had a hospitalization with subsequent decrease in his ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). There is documentation from three of the patient's medical doctors that it is medically necessary to increase PCA service hours to 24 hours/day, 7 days/week to assist the patient with ADL's and IADLs. The increase in PCA service hours are not solely for companionship and safety supervision but to assist the patient with ADLs and IADLs. The universal assessment tool cannot be used to calculate PCA service hours when the patient has unscheduled and unpredictable care needs over a particular span of time, which is the case with this patient who requires assistance with walking, locomotion, bed mobility, transfer toilet and toilet use which are to assist with unscheduled and unpredictable care needs. The patient requires cognitive prompting to assure the safe completion of medication management. 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 his home.
The patient's previous COVID infection caused him to have physical decline needing help with tasks as mentioned above.  Subsequent hospitalizations only further increased his physical limitations.  The providers recommended 24 hour PCA services as the patient has unscheduled PCA needs that span over a particular period of time.   The providers are not specifying a particular number of hours as an assessment tool would but rather that the patient needs continual support to assist with ADL's over all time/24 hours per day.