Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Increase in personal care aide (PCA) services 10 hours per day 7 days per week for a total amount of 70 hours per week.
The insurer denied an increase in personal care aide (PCA) services 10 hours per day 7 days per week for a total amount of 70 hours per week.
The determination is overturned.

The patient has a past medical history of coronary artery disease, hypertension, congestive heart failure, gastroesophageal reflux disease (GERD), gastritis, constipation, hypothyroidism, history of breast cancer, osteoarthritis, insomnia, urinary incontinence, vertigo, frequent falls, anxiety, and depression who had been assigned personal care assistant (PCA) services 5.5 hours/day, 5 days/week, to total 27.5 hours/week based on a telephonic assessment tool performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, bathing, and transfer toilet. With the tasks of managing finances, managing medication, personal hygiene, dressing upper/lower body, walking, locomotion, and toilet use the patient was assessed at limited assistance while set up only assistance with task of phone use. The patient was assessed at independent with tasks of bed mobility and eating. The patient was hospitalized with a coronovirus disease (COVID-19) infection.
Notes from a rehabilitation facility stated the patient had been admitted  and the patient's family requested discharge and the patient was discharged against medical advice. The patient underwent a telephonic assessment tool assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of transportation, bathing, personal hygiene, dressing upper/lower body, and toilet use while limited assistance with tasks of managing finances, managing medication, walking, locomotion, transfer toilet, and bed mobility. The patient was assessed as independent with task of eating. Notes from the telephonic assessment stated the patient had a decline in overall self-sufficiency following infection from COVID-19. The patient specifically noted increased muscle pains and fatigue causing difficulty with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The notes also stated the patient used a Rollator and required light touch assistance around the waist and under the arm with walking, transfers, and locomotion. The assessment also stated the patient had difficulty bending fingers and PCA help to pull patient's pants halfway and hold the patient taking some of her weight and helping patient to wipe perineal area after toilet use.
The insurer sent an initial adverse determination denial notice denying a request to increase PCA services. The patient had a magnetic resonance imaging (MRI) scan of the brain showing cortical volume loss, configuration of the ventricular system suspicious for communicating hydrocephalus, severe bilateral hippocampal volume loss which may correlate with a superimposed primary neurodegenerative process, and patchy white matter signal abnormality likely related to age-related gliosis and changes from mild chronic microvascular ischemia.
The insurer sent a final adverse determination denial notice denying request to increase PCA services stating the request was not medically necessary and the patient did not meet criteria. The denial also stated the telephonic assessment showed many of the patient's abilities to perform physical functioning stayed the same since prior assessment. In addition, the denial stated additional hours are not covered for supervision, companionship, or when tasks are not being performed by the aide. The patient's child provided a letter noting the patient had a decline in functional health due to progression of osteoarthritis and vertigo, especially after COVID-19 infection. Both daughters letter also stated the patient needed assistance from an aide during the evening hours for meal set up, personal hygiene, and preparation for bed.
The patient's primary care physician (PCP) provided a letter documenting medical necessity of personal care assistance during the night hours, 12 hours a day, 7 days/week to guarantee patient safety. The PCP letter stated the patient was homebound, unsteady on her feet, incontinent, and prone to falls. The letter further stated the patient's medical diagnoses and that her recent condition deteriorated as she had become more depressed, confused, forgetful, disoriented, occasionally agitated, and anxious. The patient's PCP documented the patient was completely dependent on caregivers and all her daily activities including walking, feeding, dressing, preparing meals, shopping, walking, and assistance in self administration of medication, and assistance to sit or stand from bed. In addition, the PCP letter stated the patient required frequent diaper changes to prevent bedsores, pressure ulcers and fungal infections. The provider documented the patient has sustained multiple falls trying to get up at night on her own. The PCP letter strongly recommended for her to have assistance 12 hours/day, 7 days/week. PCP provided a letter  stating the patient was homebound and a change in the patient's environment could lead to an exacerbation of her condition and hospitalization and he strongly recommended the patient not leave her residence unless it was a medical emergency.
At issue is the medical necessity of an increase in personal care aide (PCA) services 10 hours per day 7 days per week for a total amount of 70 hours per week.
The services were medically necessary.
The patient has documented chronic progressive medical condition of osteoarthritis and a recent MRI documenting changes consistent with dementia who had worsening functional status following COVID-19 infection. The patient requires at least limited assistance with all ADLs/IADLs except for eating. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient had an increase in assistance needs with tasks of ordinary housework, personal hygiene, dressing upper/lower body, and toilet use when comparing the assessment to her prior assessment. There was a decrease in assistance needs in the task of transfer toilet which would not be feasible given the patient's decline in functional status. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's current PCA hours and/or medical supplies and/or adaptive equipment are not sufficient to meet the patient's care needs. 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 10 hours/day, 7 days/week, to total 70 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.