Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive Decline
Treatment: Personal care worker (PCW) services 7 days/week, 12 hours/day, 84 hours/week
The insurer denied PCW services 7 days/week, 12 hours/day, 84 hours/week.
The determination is overturned.

The patient has a past medical history of congestive heart failure, hypertension, coronary artery disease, atrial fibrillation, chronic obstructive pulmonary disease (COPD), hearing loss, depression, osteoarthritis, benign prostatic hyperplasia (BPH), urinary incontinence, age related cognitive decline, and gastroesophageal reflux disease (GERD) who was receiving personal care assistant (PCA) services 4 hours/day, 5 days/week to total 20 hours/week. Physical therapy (PT) notes were provided noting the patient was at risk for falls, could ambulate with a walker 100 feet with supervision/contact guard, required maximum assistance with tasks of toilet/tub transfer, dressing, and bathing.

There was a request to increase the PCA services and the patient underwent an assessment, assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. With the tasks of stairs, transportation, bathing, dressing lower body, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of managing finances, managing medication, phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, bed mobility, and eating. Notes from the assessment stated the patient had a decline in activities of daily living (ADLs) status when compared to 90 days prior and overall self-sufficiency deteriorated in the last 90 days. A Mini-Mental State Examination (MMSE) from this assessment was 30/30.

The insurer sent an initial adverse determination denial notice partially denying the request to increase PCA services and approving an increase in PCA services to 5 hours/day, 7 days/week, to total 35 hours/week. The insurer sent a final adverse determination denial notice continuing to deny increase in PCA services, stating the patient did not meet criteria. The denial stated the patient received care from a certified home health agency with PT and recommendations for durable medical equipment (DME). In addition, the denial stated PCA services were not provided for safety monitoring and PCA services should not be authorized to the extent that the patient's needs for assistance can be met with adaptive equipment or supplies.

The patient's primary care physician (PCP) provided a letter requesting an urgent increase in hours of home care for the patient due to rapidly deteriorating mental and physical health and functional status. The provider noted it was medically necessary for the patient to have 12 hours of home care daily, 7 days/week to maintain his current health and functional capacities and prevent illness progression. Another letter was provided from the patient's health care advocate who noted that patient was unable to perform personal hygiene and could not change his diapers. The letter noted the current PT services would be ending. In addition, the letter stated 3.8 hours/day was not enough to meet the patient's care needs.

At issue is the medical necessity of personal care worker (PCW) services 7 days/week, 12 hours/day, 84 hours/week.

The services are medically necessary.

The patient's PCP documented a decline in the patient's physical and mental functioning. The assessment tool underestimated the patient's care needs for multiple tasks as per the PCP letter and advocate letter. The patient requires at least limited assistance with tasks of walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The patient requires PCA services outside of all hours that he has formal/informal help. The patient's care needs could not be met solely with adaptive equipment and medical supplies. The requested increase in PCA services was not solely for safety and supervision but to assist the patient with 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 12 hours/day, 7 days/week, to total 84 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 his own home.