Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Degenerative Osteoarthritis
Treatment: Home Health Care
The health plan denied the request for an increase in PCA hours. 
The health plan's determination is overturned.

The patient is a female with a past medical history of hypertension, renal insufficiency, severe degenerative osteoarthritis, chronic bronchitis, memory impairment, macular degeneration with visual impairment, gait impairment, urinary incontinence, and COVID-19 infection with subsequent fatigue and weakness. The patient had an assessment tool  assessing the patient at extensive assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, bathing, and dressing lower body while limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at set up only with tasks of managing finances, managing medication, and phone use while independent with tasks of bed mobility and eating. This assessment noted the patient's son was able to assist the patient with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient was assigned PCA services 5 hours/day, 7 days/week to total 35 hours/week. The patient's PCA service hours were later raised to 6 hours/day, 7 days/week to total 42 hours/week. The patient and/or provider requested an increase in PCA hours to 84 hours/week. 
At issue is the medical necessity of the requested service.

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

Yes. The patient has baseline medical conditions which necessitate assistance with ADLs and IADLs and then she contracted COVID 19 with worsening in her chronic medical conditions and functional status. There is documentation from the patient's PCP of medical necessity of increased PCA hours. The patient's multiple assessment tools show a decline in her assistance needs with tasks of meal preparation (extensive to total), ordinary housework (extensive to total), managing finances (set up to maximal), managing medication (set up to extensive), shopping (extensive to total), bathing (extensive to maximal), personal hygiene (limited to extensive), dressing upper/lower body (limited to maximal), walking, locomotion, transfer toilet and toilet use (each from limited to extensive). There is documentation that the patient had help with ADLs and IADLs from her son prior to assessment tool and no longer has informal helper. The insurers own assessments noted the patient stays in bed most of the time, is unable to bend and wash her feet, dress after shower, and raise arms fully overhead. The patient can only stand for a few minutes and PCA  helps the patient coming out of bed (OOB) to walk and ambulates very slowly with a walker. PCA services are not solely for supervision and safety but to assist the patient with safe completion with her ADLs and IADLs. The patient requires assistance with ADLs and IADLs outside of the time she has informal support. PCA 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.