Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Home Health Care- Personal Care Assistant(PCA).

The insurer denied increase in Personal Care Worker (PCW) hours. The denial is overturned.

The increase in PCW (Personal Care Worker) hours per day is medically necessary for this patient. The patient has past medical history of atrial fibrillation, prosthetic aortic valve, mitral regurgitation, congestive heart failure, coronary artery disease, history of
cerebrovascular accident, dysphagia, hearing loss, osteoarthritis, peripheral vascular disease, gastroesophageal reflux disease, macular degeneration with impaired vision, and urinary incontinence who had been assigned Personal Care Assistant (PCA) hours 7 hours/day, 7 days/week to total 49 hours/week based on an assessment tool. The assessment tool was performed over the telephone and assessed the patient at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, stairs, and transportation. The patient was assessed at limited assistance with tasks of managing medication, equipment management, bathing, dressing upper/lower body, toilet use, and eating while set up only with phone use. With tasks of personal hygiene, walking, transfer toilet, and bed mobility the patient was assessed as independent. 2 months later, the patient was hospitalized with pneumonia, possibly aspiration related, with diagnosis of Zenker's diverticulum with subsequent transfer to rehabilitation facility for five weeks. 3 months following, the patient was admitted to the hospital with gangrene to right toes. The patient subsequently underwent trans metatarsal amputation following intravenous
antibiotic treatment. There was a request to increase PCA hours following this hospital stay. An adverse determination notice with partial approval of 8 hours/day, 7 days/week to total 56 hours/week was received. The patient had a Registered Nurse (RN) visit noting the patient is chair-fast, taking soft/pureed foods and was max assist to transfer to commode. The patient's healthcare advocate provided a letter stating the patient is bedbound and dependent on her aide for transferring from bed into her wheelchair and back to bed. The letter also stated the patient does not have access to informal help and has unscheduled and reoccurring nighttime needs that cannot be met with medical equipment or supplies.
The patient had a significant change in her functional status following her hospitalization and rehab stay, and following the next hospitalization and subsequent trans metatarsal amputation. The rehabilitation notes and the physical therapy notes from the hospitalizations and surgery document the patient's functional decline and increased care needs. The patient did not have an updated assessment tool following these hospitalizations. 
The patient has unscheduled and unpredictable care needs that span over a continuum of time. The patient did not have an updated assessment tool to take these needs into account. The patient has 24 hour care needs as she needs assistance with walking, locomotion, transfer toilet, toilet use, and incontinence care. The increase in PCA care is not solely for safety and supervision but to help the patient safely complete activities of daily living (ADLs)/Instrumental activities of daily living (IADLs), 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.