Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Home Health Care 
The insurer denied an increase in personal care aide services to 5 hours per day, 5 days per week, for a total of 25 hours per week. 
The denial was overturned. 

The patient is a female with a past medical history of congestive heart failure, pulmonary hypertension, interstitial lung disease, atrial fibrillation, hypertension, mitral valve replacement, chronic anticoagulation, chronic obstructive pulmonary disease (COPD), mixed connective tissue disease, breast cancer, diabetes mellitus, neuropathy, and morbid obesity who had been assigned personal care aide (PCA) services 3.5 hours/day, 4 days/week, to total 14 hours/week based on an assessment tool. The patient saw her primary care physician (or provider) (PCP) for a mobilized wheelchair evaluation, noting the patient had a fall when transferring to the shower and was on the ground for 3 hours. The insurer sent final adverse determination denial notice, denying request to increase PCA services, stating most of the patient's abilities to perform physical functioning stayed the same, therefore current hours were sufficient to meet her needs and additional hours were not provided for companionship, supervision, or when tasks were not being performed.

The patient was seen by her pulmonary medicine provider, noting the diagnosis of interstitial lung disease. The office note also stated the patient was on 3 liters (L) of oxygen.

The patient had a visit with a physical medicine and rehabilitation provider for evaluation of a power wheelchair. 

At issue is the medical necessity of increase in PCA services level 2: 5 hours per day, 5 days per week, for a total of 25 hours per week.

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

The requested health service/treatment of increase in PCA services level 2: 5 hours per day, 5 days per week, for a total of 25 hours per week is medically necessary for this patient.

The patient has multiple chronic medical conditions affecting her mobility and functional status. The patient has chronic oxygen use with a history of interstitial lung disease, COPD, chronic anticoagulation, osteoarthritis, and mixed connective tissue disease. The patient lives alone and requires supervision with walking, locomotion, and transfer to the toilet. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to develop a plan to meet these unpredictable and unscheduled care needs. The tasking tool underestimated the patient's assistance needs and the increased time to complete tasks due to her limited mobility, morbid obesity, and shortness of breath with activities. The patient required extensive assistance with bathing on the assessment. The requested increase in PCA services 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). 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 5 hours/day, 5 days/week, to total 25 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.

Therefore, the requested health service of increase in PCA services level 2: 5 hours per day, 5 days per week, for a total of 25 hours per week is medically necessary.