Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legal Blindness
Treatment: Increase in Personal Care Services to 24 hours a day, 7 days a week (live in)
The insurer denied an increase in Personal Care Services to 24 hours a day, 7 days a week (live in)
The determination is overturned.

The patient has a past medical history of dementia, chronic anticoagulation, hypothyroidism, urinary incontinence, legal blindness, congestive heart failure (CHF), chronic kidney disease, cerebrovascular accident (CVA), spinal stenosis with chronic back pain, bilateral knee pain, and hearing loss who had been assigned personal care assistant (PCA) services 9 hours/day, 7 days/week to total 63 hours/week. The patient's geriatrician provided a letter noting the patient's medical conditions, that the patient ambulated with a walker and the assistance of another person, that she needed assistance with all activities of daily living, and 24-hour supervision was recommended to assist her with her care and to ensure her safety.
The patient's ophthalmologist provided a letter confirming the patient's diagnosis of legal blindness, as well as documenting that she had home care services and may need more hours of assistance due to her decreased vision. The patient underwent a telephonic assessment tool  assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing medication, stairs, transportation, and locomotion while maximum assistance with tasks of phone use, shopping, bathing, dressing lower body, walking, transfer toilet, and toilet use. With the tasks of managing medication, personal hygiene, and dressing upper body the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating. Notes from the assessment stated the patient's activities of daily living (ADL) status had declined and self-sufficiency had deteriorated. In addition, notes from assessment stated the patient's daughter reported the patient had a functional decline within the past 3 months and a visual decline following a hospitalization. The assessment also stated the patient's family members had been taking turns caring for the patient when a home health aide was not working, the patient was unable to sit up in bed, get out of bed and unable to stand up from bed or a chair independently. The daughter also noted the patient needed human assistance to stand up and hands-on assistance to walk with walker. The assessment further stated the patient's daughter reported the patient required assistance with toileting and providing toileting hygiene.
The insurer provided an initial adverse determination denial notice denying request to increase PCA services stating the request was not medically necessary. The denial further stated the patient was under the care of her doctor for medical conditions and the phone assessment completed found the current aide schedule could meet the patient's functional needs. The plan also recommended splitting the current hours to meet her morning and evening needs. The insurer also recommended a hospital bed to help with transfers and a bed cane to help with transfer and repositioning. In the denial letter the insurer also recommended physical and occupational therapy. Lastly, the denial stated plans were not required to allow time for safety monitoring as an independent and stand-alone function. The insurer sent a final adverse determination denial notice continuing to deny request to increase PCA services again recommending occupational and physical therapy, recommending pull-ups to keep the patient dry, a walker to move about her environment, and a personal emergency response system to use in case of emergency. The denial also stated aides do not manage behaviors or medical conditions and the patient should speak to her doctor about her medical conditions and possible treatment options to help her. The plan also stated the patient's ophthalmologist noted the patient was legally blind and aids do not manage medical conditions. They suggested a referral to community-based organization for the blind and visually impaired. The denial letter also stated personal care assistant services cannot be provided based on need for safety and supervision alone.
The patient's healthcare advocate provided a letter requesting an external appeal of denial decision by insurer. This letter stated the patient's medical diagnoses and reviewed the assessment performed, as well as the 2 denial notices. The letter further stated that the patient lived alone and the patient's daughter was undergoing treatment for cancer and could no longer provide informal support. The advocate's letter further stated that the patient's daughter had reported that the patient was unable to reheat and eat her meal after the aide had prepared it for her.
At issue is the medical necessity of an increase in Personal Care Services to 24 hours a day, 7 days a week (live in).
The services are medically necessary.
The patient has a documented decline in functional status  at which time her geriatrician recommended an increase in PCA service hours. The daughter noted the patient's worsening functional status as well, over the summer, and the patient's ophthalmologist provided documentation of her blindness. The patient has chronic and progressive medical conditions including dementia, urinary incontinence, legal blindness, chronic kidney disease, and osteoarthritis. The patient requires at least limited assistance with all activities of daily living (ADLs) and the insurer did not document a plan to meet the patient's PCA care needs outside of the hours provided by PCA. The patient no longer has informal support from her daughter as the daughter is undergoing cancer treatment. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not develop a plan to meet these unpredictable and unscheduled care needs The patient's care needs cannot be met with current PCA hours and/or adaptive equipment and/or medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs.
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 24 hours/day, live-in, 7 days/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.