Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal - Osteoporosis.
Treatment: Personal Care Services, Level 2- 8 hours per day, 7 days per week, for a total of 56 hours per week.
The insurer denied Personal Care Services, Level 2- 8 hours per day, 7 days per week, for a total of 56 hours per week.
The denial is overturned. 

The patient is a female with a past medical history of Lewy body dementia, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), chronic deep vein thrombosis (DVT), chronic anticoagulation, ampulla of vater mass, seizures, severe malnutrition, urinary incontinence, and osteoporosis who had been assigned personal care aid (PCA) services 3 hours/day, 7 days/week, to total 21 hours/week.
The patient was hospitalized due to influenza/pneumonia. There was a request to increase PCA services and the patient underwent an assessment via video assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, phone use, stairs, transportation, bathing, and transfer to the toilet. With tasks of personal hygiene, dressing upper/lower body, walking, locomotion, and toilet use the patient was assessed at limited assistance while supervision with tasks of bed mobility and eating. Notes from the assessment stated the patient had a decline in activities of daily living (ADL) status over the last days and had a deterioration in overall self-sufficiency in the last days and nursing facility level of care (NFLOC) score changed from 18 to 26.
The patient had a follow up appointment with the primary care physician (or provider) (PCP) noting the patient was wheelchair bound, for the most part, and the patient got increased home health hours but still significantly lower than what she needed given mobility limitations and dementia. 
The patient's psychiatrist sent a letter stating the patient required maximum assistance for all ADLs and had 3-4 falls in the last months as well as being mostly wheelchair bound since hospitalization and that the family had requested an increase in home health aide services. The patient was admitted to the hospital with a diagnosis of coronavirus (COVID) infection. 
At issue is the medical necessity of Personal Care Services, Level 2- 8 hours per day, 7 days per week, for a total of 56 hours per week.

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

The requested health service/treatment of Personal Care Services, Level 2- 8 hours per day, 7 days per week, for a total of 56 hours per week is medically necessary for this patient.
There is documentation of worsening cognitive and physical functioning following the patient's two hospitalizations. There is recommendation from the patient's medical providers for an increase in PCA services. The patient's Uniform Assessment System (UAS) underestimated the patient's assistance needs and the patient's cognitive and functional status has worsened. The patient requires at least limited assistance with walking, locomotion, transfer to the toilet, and toilet use. The patient has unpredictable and unscheduled care needs and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The plan assumed the patient had informal help outside of the currently approved PCA hours which was not the case as the patient's daughter works 5 to 6 days a week greater than 8 hours/day. The patient's care needs are not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL)s. 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 Personal Care Services, Level 2- 8 hours per day, 7 days per week, for a total of 56 hours per week is medically necessary.