Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee Pain
Treatment: Personal Care Aide (PCA) Level 2: 6 hours (hrs) per day 7 days per week, a total of 42 hrs a week
The insurer denied Personal Care Aide (PCA) Level 2: 6 hours (hrs) per day 7 days per week, a total of 42 hrs a week.
The determination is overturned.

This is a patient with a medical history notable for knee pain. The patient is approved for 4.5 hours per day, 7 days per week for a total of 31.5 hours per week of personal care assistance. The patient and her care team requested an increase to 6 hours per day, 7 days per week for a total of 42 hours per week. This request was denied by the health plan.
A Uniform Assessment System was completed. The assessment was conducted via video teleconference. The patient lives alone in an apartment. She was alert and oriented and able to direct her own care. Her recall was two out of three at 5 minutes and her procedural memory was intact. For her instrumental activities of daily living, the patient requires total dependence for housework. She requires maximal assistance for transportation, shopping, stairs, and meal preparation. For her activities of daily living, the patient requires maximal assistance for bathing, dressing lower body, and toilet transfer. She requires extensive assistance for walking, locomotion, toilet use, and bed mobility. She requires limited assistance for hygiene and dressing upper body. The patient has diagnoses of lupus, arthritis, and hypertension. She had recently had knee replacement surgery and bilateral knee issues cause difficulty with activities of daily living. She requires some weight-bearing caregiver assistance when changing positions, including transferring, bathing, and dressing. The patient is continent of both urine and stool. There was no fall in the previous 90 days. A task tool associated with the assessment recommended 5.5 hours per day or 38.5 hours per week to address the patient's personal care needs. Compared to a prior assessment, the patient demonstrated a decline in level of function for activities of daily living. The prior assessment recommended 4.5 hours per day to address her needs. There were no medical records or letters of medical necessity provided as part of this appeal. At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 6 hours (hrs) per day 7 days per week, a total of 42 hrs a week.

The requested health service of Personal Care Aide (PCA) Level 2: 6 hrs per day 7 days per week, a total of 42 hrs a week is medically necessary for this patient.
The updated assessment outlines that the patient requires more weight-bearing assistance with activities of daily living. The task tool also reflects that an increase in hours is most likely required for the patient given that her level of functioning has declined. The task tool recommended at least 38.5 hours per week to address the patient's personal care needs, which might be seen as a minimum reasonable level to complete all of her activities of daily living and other personal care tasks. Therefore, the requested increase to 42 hours per week is medically necessary and appropriate for the patient. Failure to increase her amount of personal care assistance in light of her declining level of function could result in falls and/or injuries.