Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. The insurer denied increase in Personal Care Assistance (PCA) Service to 2 x 12 hours/day x 7 days/week Split Shifts, total 168 hours/week. 

The denial is overturned in whole.

The patient is a female with past medical history of dementia, breast cancer, hearing loss, hypertension, osteoporosis, anemia, bladder incontinence, and bowel incontinence who had been assigned Personal Care Assistance (PCA) services 7 hours/day, 7 days/week, to total 49 hours/week based on telephonic assessment performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, phone use, and shopping while maximum assistance with tasks of managing medication and equipment management. With tasks of stairs, transportation, bathing, and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of dressing upper body and toilet use. The patient was assessed at supervision with tasks of personal hygiene, walking, locomotion, and eating while independent with task of bed mobility.

The patient underwent an assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, transportation, equipment management, bathing, dressing lower body, and toilet use. With tasks of stairs, personal hygiene, dressing upper body, and transfer toilet the patient was assessed at extensive assistance while limited assistance with tasks of walking and locomotion. The patient was assessed at supervision with task of eating and independent with task of bed mobility. Notes from the assessment noted the patient lived alone, was unable to express care goals due to cognitive impairment, wore a wandering alarm, did not know how to call 911, and there was a decline in activities of daily living (ADL) status over the last 90 days and a deterioration of overall self-sufficiency over the last 90 days. The subject under review is the medical necessity for the increase in hours to 2 x 12 hours/day x 7 days/week Split Shifts, total 168 hours/week.

The health plan's determination is overturned.

There is documentation by patient's primary care physician (PCP) of functional and cognitive decline. There is documentation from assessment tool of worsening functional and cognitive decline when comparing assessments. Although the patient was approved for PCA services 24 hours/day, 7 days/week, live-in, there is documentation of the patient requiring assistance with care needs at least every 2-3 hours overnight. The patient requires at least limited assistance with tasks of walking, locomotion, 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 requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 2 x 12 hours/day, 7 days/week, split shifts 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.