Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart disease
Treatment: Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week: Total of 84 Hours per week.
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week: Total of 84 Hours per week.
The health plan's determination is overturned.

This is a case review for a female with a medical history notable for incontinence, diabetes, and arthritis. The patient and her care team requested an increase to 12 hours per day, 7 days per week, for a total of 84 hours per week.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has multiple medical problems, including urinary incontinence, pressure ulcers on the sacrum, difficulty walking, congestive heart failure, venous insufficiency, osteoarthritis, chronic obstructive pulmonary disease (COPD), and diabetes. The physician states that the patient's clinical status has significantly deteriorated. The patient is unable to toilet or manage incontinence care products without assistance. She has difficulty using her walker without assistance. She has open skin areas on the buttocks that require frequent diaper changes that she cannot complete on her own. The patient had a fall in some month ago as a result of attempting to complete personal care tasks without a care aide. Therefore, they recommend an increase in personal hours as necessary for the patient.
A uniform assessment system was completed via video teleconference. The patient lives alone in a studio apartment. She was alert and oriented, but forgetful at times. She has a diagnosis of mild cognitive impairment. She recently began forgetting who some people are. Her recall was two out of three after 5 minutes. For her instrumental activities of daily living, the patient requires total dependence with housework. She requires maximal assistance for meal preparation, finances, medications, stairs, and transportation. For her activities of daily living, the patient requires maximal assistance for bathing, dressing the lower body, walking, locomotion, toilet transfer, toilet use, and bed mobility. She requires extensive assistance for hygiene and dressing the upper body. She is independent for eating. She is frequently incontinent of urine and occasionally incontinent of stool, and she wears pull-ups and diapers for incontinence care. There were two or more falls in the previous 30 days. Compared to a prior assessment, the patient showed a decline in functional status.

The requested health service of Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week: Total of 84 Hours per week is medically necessary for this patient.
The patient requires personal care assistance with essentially all activities of daily living. She is unable to ambulate, toilet, or manage incontinence care without assistance. Her daughter provides some informal support, but the patient mostly lives alone. Her recent falls while attempting to perform personal care tasks independently are the result of unmet personal care needs. Furthermore, she has developed pressure ulcers on the sacrum. The requested increase to 12 hours per day of personal care assistance is medically necessary and reasonable for the patient. Failure to provide for her personal care needs could result in additional falls, infection, or worsening skin breakdown.