Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular Disorder
Home Health Care

Diagnosis: Mobility Issues, Seizures, Dementia
Treatment: Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week
The insurer denied the Personal Care Aide (PCA) Level 2 Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week.
The health plan's determination is overturned.

The patient is a male with a past medical history of cerebrovascular accident (CVA), seizure disorder, hypertension, atrial fibrillation, chronic anticoagulation, neuropathy, cognitive impairment, osteoarthritis, glaucoma, urinary incontinence, and bowel incontinence. He had been assigned PCA services 6 hours per day, 7 days per week, to total 42 hours per week based on an assessment performed in person. The patient was assessed at total assistance with the tasks of meal preparation, ordinary housework, managing finances, managing medication, and shopping while he was at maximum assistance for all other tasks. The tasking tool estimated 66.5 hours per week. The patient had a hospitalization for Coronavirus (COVID-19) with acute respiratory failure and pneumonia with subsequent transfer to a rehabilitation facility. The interdisciplinary discharge planning instructions from the rehabilitation facility stated that the patient required a 2 person assist with getting in and out of bed, using the toilet, and personal hygiene.

The patient's primary care physician (PCP) provided a letter noting the patient's recent hospitalization and subsequent rehabilitation stay stating the patient was unable to complete most basic daily tasks on his own and required an assistive device and an individual to assist him with ambulation. In addition, the letter stated that the patient needed a private automobile for any transportation needs. There was a request to increase PCA services and the patient had a video assessment performed assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, and transportation while he was assessed at maximum assistance with all other tasks. The tasking tool estimated 66.5 hours per week. Notes from an assessment stated the patient had severe cognitive impairment with behavioral disturbances and the family never left the patient alone. The assessment also noted that the patient had hemiparesis on the right side as a result of a previous stroke, the patient had an increase in tremors, the patient utilized a walker indoors and a wheelchair outdoors, and the patient required assistance with toileting and post toileting care.

The patient requires at least maximum assistance with walking, locomotion, toilet transfers, and toilet use and therefore has an unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The plan assumed the patient had informal help outside of the currently assigned PCA services, which is not the case.

The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL's) and Instrumental activities of daily living (IADL's). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours per day, 7 days per week, to total 84 hours per week are medically necessary for this patient. 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 his own home.