Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, atrial fibrillation on chronic anticoagulation.
Treatment: Increase in Personal Care Aide (PCA) services; Level 2: 10 hours a day-7 days per week for a total of 70 hours per week.

The insurer denied an Increase in Personal Care Aide (PCA) services; Level 2: 10 hours a day-7 days per week for a total of 70 hours per week.  The determination is overturned.

The patient has a past medical history of coronary artery disease, congestive heart failure, atrial fibrillation on chronic anticoagulation, permanent pacemaker, edema, diuretic use, hypertension, anxiety/depression, osteoarthritis, urinary incontinence, and constipation who had been assigned personal care assistant (PCA) services 5.5 hours/day, 4 days/week and 4.5 hours/day, 3 days/week to total 35.5 hours/week.
The patient had an in person assessment assessing the patient at maximum assistance with the tasks of meal preparation, stairs, shopping, and bathing while extensive assistance with tasks of transportation, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With the tasks of managing finances and managing medication the patient was assessed at limited assistance while independent with tasks of phone use, bed mobility, and eating.

The patient's primary care physician (PCP) provided a letter stating the patient had multiple medical problems, and her medical conditions had worsened. The letter further stated the patient's judgment was not as good as it had been before, and she forgets to take her medications and eat. In addition, the letter stated the patient had dizzy spells and increased episodes of falls over the last month, was unsteady, slow, and experiences lack of balance. Lastly, the letter stated the patient relied on home health aide for all her activities of daily living (ADLs) and recommended increased home health aide hours in order to keep her safe.

At issue is the medical necessity of an increase in Personal Care Aide (PCA) services; Level 2: 10 hours a day-7 days per week for a total of 70 hours per week.

The services are medically necessary.

There is documentation from the patient's providers that the patient has had a decline in physical functioning. There is also documentation from her cardiologist and PCP that it is medically necessary for her to have an increase in PCA hours. The patient requires PCA assistance outside of the time that she has informal help. The patient requires assistance with locomotion, walking, transfer toilet, and toilet use. 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's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of 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 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.