Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic Brain Injury.
Treatment: Increase in personal care assistance (PCA) services from 40 to 84 hours per week.

The insurer denied an increase in personal care assistance (PCA) services from 40 to 84 hours per week.  The determination is overturned.

The patient has a past medical history of traumatic brain injury, migraine, hypertension, bladder incontinence, insomnia, gastroesophageal reflux disease (GERD), constipation and depression who had been assigned 40 hours of personal care assistant (PCA) services. There was a request to increase services and the patient underwent a telephonic assessment tool  assessing the patient at total assistance for meal preparation, ordinary housework, and shopping while maximum assistance with managing finances and transportation. With the tasks of managing medication, phone use, stairs, equipment management, bathing, personal hygiene, and dressing upper/lower body the patient was assessed at extensive assistance while limited assistance with tasks of walking, locomotion, transfer toilet, and toilet use. The patient was assessed as supervision with eating and independent with bed mobility. The patient's healthcare advocate provided a letter requesting an expedited plan appeal of the denial of services requested. The letter noted the patient's safety was at immediate risk without caregivers to provide her with maximal assistance with activities of daily living (ADLs) from the time she wakes until she retires in the evening, is left with no one to assist with ADLs on evenings and weekends at current hours, a nursing assessment done outlined that the patient could not be left unattended with walking, dressing, toileting, and showering and always needed transfer assistance and assistance with ambulating. The healthcare advocate's letter also stated the patient had loss of brain function related to 3 separate brain aneurysms and because of deterioration of her brain function the patient had become incontinent of bladder and could no longer ambulate, toilet, shower, transfer, dress, cook or take her medications independently. Lastly, the letter stated the patient lived alone and her children work full-time and were not unable to assist her in her daily care. The insurer sent a final adverse determination denial notice denying request to increase PCA services to 12 hours/day, 7 days/week, to total 84 hours/week and stating the current hours given under last authorization were enough to meet her needs. The plan further recommended the patient follow-up with her doctor regarding symptoms she was reporting. The patient's healthcare advocate provided another letter requesting an expedited external appeal of the denial of services requested. At issue is an increase in personal care assistance (PCA) services from 40 to 84 hours per week.

The services are medically necessary.

The patient has a documented decline in functional status related to traumatic brain injury secondary to multiple brain aneurysms with resultant urinary incontinence. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient's ADLs/ instrumental activities of daily living (IADL) care needs cannot be met with the current hours and/or adaptive equipment and/or medical supplies. The plan assumed the patient had informal help outside of the hours of PCA assistance. 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 hours/day, 7 days/week, to total 84 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.