Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous System/Neuromuscular Disorder. 
Treatment:  Increase in PCA hours to 9 hours per day 7 days a week. 

The insurer denied increase in PCA hours to 9 hours per day 7 days a week.  The denial is overturned.

The patient is a female with past medical history of chronic pain, progressive dementia, anxiety, depression, hypertension, coronary artery disease, congestive heart failure (CHF) stage IV, hyperlipidemia, hypertensive nephropathy, osteoporosis, orthostatic hypotension, bilateral knee arthritis, lumbar radiculopathy, peripheral edema, insomnia, impaired vision, and urinary incontinence who had been assigned Personal Care Assistance (PCA) services 6 hours/day, 7 days/week to total 42 hours/week based on assessment tool performed.  

The patient's primary care physician (PCP) wrote a letter requesting an urgent increase in hours for home care. The PCP letter noted the patient had rapidly deteriorating mental state and physical health, resides alone, suffers from chronic pain, has reduced mobility, has severe stamina loss, has poor functional status, has increased pain and difficulty in walking and standing, suffers from cognitive impairment related to progressive dementia with paranoia, has progressive disorientation, has decreased verbal communication, has chronic insomnia and fatigue, has nighttime agitation and irritability, is completely dependent on others, is high risk for fall, requires multiple daytime and nighttime changes of soiled diapers and linens to prevent skin rash and irritation, and recommended 12 hours of PCA services daily, 7 days/week.

The subject under review is the requested increase in PCA hours to 9 hours per day 7 days per week.

The health plan's determination is overturned.

There is documentation of progression of the patient's chronic medical illnesses and worsening functional and mental status. The patient had documented increased assistance needs with meal preparation, ordinary housework, managing medication, bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use when comparing assessment tools. The first assessment noted the patient had 12 hours per week of social daycare that ended with Covid pandemic. The next assessment tool noted the patient had no informal helper while she was noted to have two informal helpers at the first assessment. The patient has assistance needs with all tasks except bed mobility and eating. The patient has unscheduled and unpredictable care needs specifically with walking, locomotion, transfer toilet, and toilet use. The patient's PCP documented the patient's functional and mental decline. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of Instrumental activities of daily living (IADLs)/activities of daily living (ADLs).  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 9 hours/day, 7days/week, to total 63 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.