Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure
treatment: Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week (Split Shift) for a Total of 168 Hours per Week. 
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week (Split Shift) for a Total of 168 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of hypothyroidism, congestive heart failure on chronic oxygen therapy, dementia, anxiety, diabetes mellitus type 2, hyperlipidemia, seizure disorder, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), coronary artery disease, right shoulder dislocation, cerebrovascular accident (CVA) with right hemiplegia, dysphagia with percutaneous endoscopic gastrostomy (PEG) tube, urinary incontinence, and bowel incontinence who had been assigned PCA (personal care aide) services following an assessment tool performed via telephone assessing the patient at total assistance for all activities of daily living (ADL) and Instrumental activities of daily living (IADL) . Notes from this assessment stated the patient was receiving consistent informal help and supervision after the PCA left due to the patient pulling at PEG tube, pulling at oxygen tubing, and needing turning and repositioning. In addition, notes stated the patient was pushed by wheelchair and a Hoyer lift with 2 people was used for transfers.

Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week (Split Shift) for a Total of 168 Hours per Week is medically necessary for this patient. 
The patient requires total assistance with all ADLs and IADLs. The patient's family was privately paying for assistance in the overnight hours. The family could no longer afford to pay for this assistance. The patient's Primary Care Physician (PCP) provided a letter stating the patient required turning and repositioning every 2 hours to prevent skin breakdown and infection. 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 in the overnight hours. The patient's care needs in the overnight hours would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase for PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's primary care provider has documented medical necessity of PCA services 24 hours/day, 7 days/week, split shift. 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 24 hours/day, split-shift, 7 days/week, to total 168 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.