Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mobility Issues
Treatment: Increase in Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day/7 Days per Week, 12 Hours per Day/7 Days per Week (Split Shift) for a Total of 168 Hours per Week.
The insurer denied an increase in Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day/7 Days per Week, 12 Hours per Day/7 Days per Week (Split Shift) for a Total of 168 Hours per Week.
The determination is overturned.

The patient has a past medical history of hypertension, hyperlipidemia, coronary artery disease, lumbar spinal stenosis, cervical disc disease, insomnia, bilateral foot drop, dementia, neuropathy from Lyme disease, bladder incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services 4 hours/day, Monday through Friday, to total 20 hours/week based on assessment performed via telephone assessing the patient at total assistance with tasks of ordinary housework, stairs, and transportation while maximum assistance with tasks of meal preparation, bathing, dressing lower body, walking, locomotion, and transfer toilet. The patient was assessed at extensive assistance with tasks of shopping, dressing upper body, toilet use, and bed mobility while limited assistance with tasks of equipment management, personal hygiene, and eating. Notes from this assessment stated the patient had pain and stiffness in the knees, lower back, and shoulders, had hand tremor, was able to wheel himself less than 1 foot, was able to stand less than 10 seconds, had weight bearing support to wipe, and change pull-ups, was reminded to take medication, and had informal help from child or child in law.
The patient had a hospitalization for decubitus wound infection and was transferred to rehabilitation. The patient had stage IV pressure ulcers to the right heel and sacrum. Notes from rehabilitation stated the patient's elderly cousin stayed with the patient overnight prior to hospitalization but was not able to change the patient's diapers and felt to be reason for sacral ulcers. Notes also stated the patient had rapid decline and was nonambulatory and was dependent on all activities of daily living (ADL) / instrumental activities of daily living (IADL) s. The patient was substantial/maximal assistance with sitting to lying and lying to sitting on the edge of the bed, sit to stand, bed to chair transfer, toilet transfer, and car transfer. The patient was dependent for any ambulation and was not able to wheel himself. Occupational therapy notes from rehabilitation stated the patient was partial to moderate assistance with eating and oral hygiene while substantial/maximum assistance with upper body dressing and rolling left to right. The patient was dependent with toileting hygiene, shower and bathing, lower body dressing, and toilet transfer. Wound care notes were provided and the patient was seen approximately every 1 to 2 weeks.
There was a request to increase PCA services and the patient underwent a telephonic assessment tool assessing the patient at total assistance with meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, locomotion, and toilet use. It noted that transfer of toilet activity did not occur and there was no estimation of assistance needs. The patient was assessed at maximum assistance with tasks of bathing, personal hygiene, dressing upper body/lower body, walking, bed mobility, and eating. Notes from the  assessment stated that the patient was moderately cognitively impaired, would live with his cousin who was unable to provide ADL support and had no informal helper. The insurer sent an initial adverse determination denial notice denying request to increase PCA services to 12 hours x 12 hours, split shift, 7 days/week to total 168 hours/week but did approve 7 hours/day, 7 days/week to total 49 hours/week. The denial stated the request was not medically necessary and recommended adjusting service hours to better suit his needs. The rehab provider supplied a letter of unknown date, stating the patient was admitted with sacral stage IV pressure ulcers, bilateral foot drop with bilateral ankle foot orthosis (AFO), and poor sensory/motor control of trunk and all 4 extremities. The letter further stated the patient demonstrated cognitive deficits for manipulation of environment, poor insight into functional abilities/limitations, and decreased safety awareness. In addition the letter stated the patient required continuous verbal, tactile, and visual cues for safe bed mobility, functional transfers, ambulation and stair negotiation. Lastly, the letter stated the patient required maximum assistance with all functional mobility, activities of daily living, and upon discharge required supervision and assistance in the form of an aide 24 hours/day. The insurer sent a final adverse determination denial notice denying to increase PCA services and stating the plan approval stayed at 4 hours/day, 5 days/week to total 20 hours/week. The denial letter stated the patient required total dependence on locomotion, toilet transfer, toilet use, meal preparation, medication management and housework. In addition, the denial letter stated time had been allotted for meal preparation, laundry, and housework and the patient had a wheelchair and incontinence supplies to assist with personal care needs. The denial stated the patient's care needs could be met with services 7 hours/day, 7 days/week to total 49 hours/week. Lastly, the denial stated additional hours are not granted when tasks are not being performed and for safety monitoring and supervision. The patient's healthcare advocate provided a letter requesting external appeal of denial decision by insurer. This letter stated that the patient had a deterioration in physical condition in the most recent months and had poor and unsafe decision making. In addition, the letter stated that the patient's bowel incontinence worsened with the need for increased toileting visits per day. The letter also stated the patient required repositioning every 2 hours because of sacral and right heel pressure ulcers. At issue is the medical necessity of an increase in Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day/7 Days per Week, 12 Hours per Day/7 Days per Week (Split Shift) for a Total of 168 Hours per Week.
The services are medically necessary. The patient has documented chronic and progressive medical conditions of osteoarthritis and dementia with chronic pressure ulcers of sacrum and right heel. The patient has documented worsening functional and cognitive status. The patient requires assistance with all ADLs/IADLs. The patient has no informal helper. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan for these unscheduled and unpredictable care needs. The patient's ADL/IADL assistance needs cannot be met with current hours and/or adaptive equipment and/or medical supplies. The patient requires repositioning every two hours as well as toileting for urinary and bowel incontinence with sacral decubitus and a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The request for increased PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/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 12 x 12 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 his own home.