Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall Risk. 
Treatment: Personal care aide (PCA) level 2: 12 hours per day- 7 days per week- a total of 84 hours per week. 

The insurer denied personal care aide (PCA) level 2: 12 hours per day- 7 days per week-a total of 84 hours per week. 
The determination is overturned. 

The patient has a past medical history of Meniere's disease, major depressive disorder, anxiety, urinary incontinence, insomnia, diabetes mellitus type 2, hypertension, breast cancer, osteoarthritis, and left arm weakness who had been assigned personal care assistant (PCA) services 9 hours/day, 7 days/week, to total 63 hours/week based on an assessment tool performed via telephone which assessed the patient at total assistance with the tasks of ordinary housework while maximum assistance with the tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, dressing upper/lower body, walking, and locomotion. With the tasks of managing finances, personal hygiene, transfer toilet, and bed mobility the patient was assessed at extensive assistance while limited assistance with tasks of toilet use. The patient was assessed at supervision for task of eating while independent with task of phone use. Notes from the telephonic assessment noted the patient's activities of daily living (ADL) status compared to 90 days ago had declined and overall self-sufficiency had deteriorated when compared to 90 days ago. This assessment also stated the patient had falls. 
The patient's primary care physician (PCP) provided a letter stating the patient's medical conditions and requesting an increase in home care services. The patient underwent an assessment tool assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, dressing upper/lower body, walking, locomotion, and transfer toilet. With the tasks of managing finances, personal hygiene, transfer toilet, and bed mobility the patient was assessed at extensive assistance while supervision with the task of eating and independent with task of phone use. Notes from the assessment noted the patient's ADL status compared to 90 days ago had declined and overall self-sufficiency had deteriorated compared to 90 days ago.
The patient's neurologist provided a letter noting the patient's medical diagnoses including diabetic neuropathy, orthostatic hypotension, multifactorial ataxia, multiple repeated falls, vestibulopathy with unsteady gait and status post coronovirus disease 2019 (COVID-19) . The letter also stated the patient required assistance in performing all of her daily activities including but not limited to ambulating, feeding, bathing, dressing, cooking, shopping, supervising medication intake, and attending her medical appointments. The neurologist also recommended that the patient should not be left alone anytime of the day and required supervision around-the-clock and night to provide safe and clean environment, optimal nutrition and hydration, and to prevent falls and injuries. Lastly, the letter stated the patient requires assistance with standing up from sitting position, assistance with ambulating due to ataxia, dizziness and imbalance, and the patient has had several falls with loss of consciousness at nighttime when she could not get up and had to stay on the floor until her aide came in the morning. 

The insurer provided an initial adverse determination denial notice denying the request to increase PCA services stating it was not medically necessary. The patient's psychiatrist provided a letter stating the patient had a fall and her cognitive and physical problems became worse. The letter also stated the patient showed more deterioration in her memory, concentration, and comprehension since her most recent diagnosis and her balance and gait had become more unstable, which has caused repeated falls. In addition, the letter stated the patient's Instrumental activities of daily living (IADLs) score was 21/24 and her Katz index of activities of daily living score was 3/6, which implied a dependence on a caregiver. Lastly, the letter stated it was the psychiatrist's professional opinion that the patient was in need increased home care hours to help with activities of daily living during the day and in the late evening. 

The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating they had a follow-up telephonic clinical assessment showing many of her abilities to perform physical functioning stayed the same since her prior assessment. The denial also stated additional hours are not provided for stand-alone safety supervision, companionship or when the aide is not performing tasks. The patient appealed the denial decision. The patient's PCP provided a letter stating the patient's medical diagnoses, that the patient lived alone, she had had multiple falls at home over the last 2 months when left unattended, had gait instability increasing over the last 6 months, had chronic low back pain with increase in the last 3 months, and the patient needed increase in her home care services as soon as possible (ASAP) to at least 10 hours/day, 7 days/week to ensure the patient's safety. 

At issue is the medical necessity of personal care aide (PCA) level 2: 12 hours per day- 7 days per week- a total of 84 hours per week. 

Yes. The services are medically necessary. There is documentation of worsening physical functioning related to her multiple medical conditions, specifically orthostatic hypotension, multifactorial ataxia with resultant multiple falls. Her neurologist noted that the patient requires assistance when standing up from sitting position and assistance with ambulation due to ataxia, dizziness, and imbalance. The patient requires assistance with all tasks except for phone use, and the patient would require PCA assistance during the hours that she does not have informal help. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's assistance needs cannot be met solely with medical supplies and adaptive equipment. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer has not developed a plan to meet these unpredictable and unscheduled care needs when she does not have informal help. 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.