Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Personal Care Aide (PCA) Level 2: 6 hours/day, 5 days/week, for a total of 30 hours/week
The insurer denied PCA Level 2: 6 hours/day, 5 days/week, for a total of 30 hours/week.
The denial is overturned in whole. 

The patient is a female with a past medical history of anxiety, osteoporosis, uterine cancer, metastatic breast cancer, urinary incontinence, hypertension, hyperlipidemia, monoclonal gammopathy of undetermined significance (MGUS), gastroesophageal reflux disease (GERD), hypothyroidism, and anemia who had been assigned personal care aide (PCA) services 3.5 hours a day, 5 days/week, to total 17.5 hours/week based on telephonic assessment tool. Client task sheet estimated 4 hours of services per day.

The patient had a fall and did not seek medical care. There was a request to increase PCA services and the patient underwent an assessment, assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, shopping, and transportation while extensive assistance with task of stair use. The patient was assessed at limited assistance with tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer to the toilet, and toilet use while supervision with task of bed mobility. With task of eating the patient was assessed at independent. The client task sheet estimated 4.5 hours/day of assistance needs.

The insurer sent final adverse determination denial notice stating the patient lived with her spouse and her children were supportive and involved in her care. The patient's primary care physician (or provider) (PCP) provided a letter stating it was his medical opinion that the patient receive services in-house 5.5 hours/day, 7 days/week, to assist with all activities of daily living (ADLs). The patient's daughter provided a letter. The daughter noted the patient was bed ridden for about 8 months and she started radiation therapy because she was too underweight for a surgery. In addition, the daughter's letter stated the patient lived with her husband, but he had been having medical issues and was unable to care for himself or the patient. 

At issue is the medical necessity of PCA Level 2: 6 hours/day, 5 days/week, for a total of 30 hours/week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of PCA Level 2: 6 hours/day, 5 days/week, for a total of 30 hours/week is medically necessary for this patient.

There is documentation of worsening functional status of the patient by her PCP, her daughter, and the assessment performed by the insurer. The patient required increased assistance with tasks of managing finances, stairs, shopping, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer to the toilet, toilet use, and bed mobility. The plan assumed the patient had informal help from her family, including her spouse, but per documentation provided the husband was not able to provide informal help nor was the patient's daughter or her other two children. The patient requires assistance with ADLs and instrumental activities of daily living (IADLs) outside of the time she does 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. 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.

Therefore, the requested health service/treatment of PCA Level 2: 6 hours/day, 5 days/week, for a total of 30 hours/week is medically necessary.