Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, atherosclerotic cardiovascular
disease, hypertension, gastroesophageal reflux disease
Treatment: Increase Personal Care (PCA) Level 2:10 Hours Per Day -7 Day (s) Per Week- For A Total of 70 Hours Per Week
The insurer denied the Increase Personal Care (PCA) Level 2:10 Hours Per Day -7 Day (s) Per Week- For A Total of 70 Hours Per Week.
The denial is upheld.

This patient is a male with diagnoses including osteoarthritis (OA), atherosclerotic cardiovascular disease (ASCVD), hypertension (HTN), gastroesophageal reflux disease (GERD), hyperlipidemia (HPL), atrial (A)-fibrillation, peripheral vascular disease (PVD) and is status post (s/p) a fall with elbow fracture. The patient has joint pain, stiffness, limited range of motion (ROM), unsteady gait, and weakness.

The patient was admitted to skilled nursing facility (SNF) after undergoing surgery for elbow fracture. He was admitted for one day due to pain and discharged back to skilled nursing facility (SNF). The patient lives alone. The patient is appealing the denial for increase in personal care aide (PCA) services from 35 to 70 hours per week.

Assessment performed shows short-term memory problem and functional status:
total dependence with housework; maximal assistance with meal preparation,
shopping, bathing, and dressing; extensive assistance with transportation, personal
hygiene, walking, locomotion, toileting, and bed mobility; limited assistance with
managing medications, and eating; and set up with managing finances and phone.
The patient has a cane, shower chair and walker to assist with needs. This shows
decline from assessment performed where max assistance with housework;
supervision with medications; and limited assistance with bathing, personal
hygiene, dressing and toileting; and independent with bed mobility. As a result of
the most recent assessment, the patient was approved for 28 hours of personal
care aide (PCA) services. An appeal letter from her doctor states the patient has
multiple conditions and repeated history of falls. Uses a walker to ambulate with
assistance. It states the patient is in constant need of assistance to perform
activities of daily living (ADLs).

No, the proposed Increase Personal Care (PCA) Level 2:10 Hours Per Day -7 Day
(s) Per Week- For A Total of 70 Hours Per Week is not medically necessary.

Medically necessary services are those which are:
1) safe
2) effective
3) generally accepted national standard of medical practice
not provided primarily for convenience of the patient or the practitioner
the least intensive and/or most appropriate alternatives among diagnostic and
treatment options.

The proposed treatment is not medically necessary because it is not consistent with
generally accepted national standard of medical practice.

Level II personal care service is indicated for individuals that need assistance with
housekeeping, cleaning, meal preparation, grocery shopping, and laundry as well
as assistance with personal needs, including bathing, dressing, grooming, toileting,
walking, feeding, assisting with administering medications, preparing meals with
special diets, and routine skin care.

This patient has multiple chronic medical conditions with limited mobility and a fall.
Assessment performed after hospitalization and skilled nursing facility stays, shows
a decline in the patient's functional status compared to assessment performed prior.
As a result the patient's personal care aide (PCA) service hours were increased
from 28 to 35 hours. The most recent assessment shows the patent needs
assistance with housework, meal preparation, shopping, bathing, dressing,
transportation, personal hygiene, walking, locomotion, toileting, bed mobility,
managing medications, and eating. The provider's appeal for increase in hours is
based on need for assistance with activities of daily living (ADLs) that are already
accounted for in the most recent assessment. The approved 35 hours per week are sufficient to provide assistance with activities of daily living (ADLs) and personal
care as noted above. Personal care services (PCS) are not indicated for
management of chronic medical conditions and is not indicated when there are no
tasks being performed. The proposed increase in personal care services (PCS) to
a total 70 per week is not medically necessary to meets this patient's need for
assistance with activities of daily living (ADLs) and personal care.