Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
Treatment: Increase in personal care worker (PCW) service from 7 days per week, 4 hours per day to 7 days per week, 12 hours per day.

The insurer denied increase in personal care worker (PCW) service from 7 days per week, 4 hours per day to 7 days per week, 12 hours per day. The health plan's determination is overturned.

The patient has a past medical history of bowel incontinence, bladder incontinence, hearing impairment, breast cancer, dementia, osteoporosis, benign paroxysmal vertigo, osteoarthritis of the knee, chronic atrial fibrillation, history of falling, and low back pain who had been assigned personal care assistant (PCA) services 4 hours/day, 7 days/week, to total 28 hours/week based on an assessment tool. The patient was assessed at extensive assistance with task of transportation while limited assistance with task of managing finances, managing medication, stairs, and equipment management. The patient was assessed as independent with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility.
There was a request to increase PCA hours and the patient had a phone assessment tool performed assessing the patient at maximal assistance with tasks of ordinary housework while extensive assistance with tasks of meal preparation, managing finances, managing medication, phone use, stairs, shopping, transportation, and equipment management. The patient was assessed at limited assistance with tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The assessment noted the patient had two informal helpers and her self sufficiency deteriorated. The patient had physical therapy (PT) recertification noting the patient had poor balance and limited range of motion at the cervical spine. The daughter in law wrote a note to the patient's primary care physician (PCP) stating the patient has had a decline in the last two months, has had unexplained weight loss, had fallen twice while alone in the home, has increased confusion and memory loss. Another letter from the patient's daughter in law was provided stating over the past month the patient is frequently confused, has increased difficulty managing her medication, has worsening balance, is unable to hold her head up for more than a few minutes due to kyphosis, has had multiple falls in the last few months, has had increased incontinence with the need for assistance to clean herself, has increased laundry due to increased incontinence, is unable to cook food or retrieve from the microwave, and is unable to take out the trash/recycling.
The insurer sent a final adverse determination denial notice stating the request to increase services was not medically necessary and did not meet criteria. The denial stated based on assessment tool performed current level of care is enough to meet the patient's needs. In addition, the denial stated extra hours are not required to include safety monitoring as a separate task. The patient's cardiologist provided documentation of the patient's diagnoses and the patient should have increase in PCA hours to assist at home and prevent further hospitalizations. This office note also stated "it is imperative that the patient have her home health care agency increase the hours of home attendant from 4 hours/day to 8-10 hours/day. The patient's daughter in law provided another letter stating the patient's condition is progressively worsening, had another fall, has bowel and urinary incontinence requiring help cleaning up after accidents, and is not eating properly and has lost weight. On the same date the patient's family appealed the denial decision. At issue is the medical necessity of an increase in personal care worker (PCW) service from 7 days per week, 4 hours per day to 7 days per week, 12 hours per day.
The requested services are medically necessary. The patient has chronic progressive medical illnesses of osteoarthritis and dementia with documented decrease in functional status. The patient had increased assistance needs with activities of daily living (ADLs)/instrumental activities of daily living (IADLs) when comparing the assessment tools. The patient's primary care provider (who is a cardiologist) documented the patient's increased need for help with ADLs/IADLs. The patient's daughter in law further stated the patient's increased care needs with meal preparation, managing medication, transfer toilet, toilet use, incontinence care, and eating. An increase in PCA hours for this patient is not solely for safety and supervision but to assist the patient with safe completion of ADLs/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.