Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Home Health Care

Diagnosis: Osteoporosis/unsteady gait
Treatment: Personal Care Aide 
The insurer denied Personal Care Aide (PCA) Level 2: Live-In Per Diem for 24 Hours per Day/7 Days per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of colon cancer, hypertension, hyperlipidemia, diabetes mellitus, osteoporosis, atrial fibrillation on anticoagulation, Alzheimer's dementia, osteoarthritis, unsteady gait, urinary incontinence, and bowel incontinence who had been assigned PCA (personal care assistant) service hours. The patient was noted to need total assistance with tasks of ordinary housework, managing finances, stairs, shopping, transportation and locomotion while maximum assistance with tasks of meal preparation, managing medication, bathing, dressing lower body, walking, transfer toilet and toilet use. At this assessment, the patient was assessed at extensive assistance for tasks of personal hygiene, dressing upper body, bed mobility, limited assistance with task of phone use and supervision for task of eating.

Personal Care Aide (PCA) Level 2: Live-In Per Diem for 24 Hours per Day/7 Days per Week are medically necessary for this patient. 

There is documentation in the patient's medical record of worsening physical and cognitive abilities. The patient has the diagnosis of osteoarthritis and dementia which are both progressive illnesses worsening with age. The patient had more noticeable decline following her last assessment as documented in medical records. Although the patient has documented wandering and confusion at night, increase in PCA service hours is not solely for supervision and safety but to assist the patient with unscheduled and unpredictable care needs in the hours that the PCA is not available. It is documented that the patient does not have an informal helper during the hours she doesn't have a PCA. The patient had diagnosis of urinary and bowel incontinence with the documented need for assistance with transfer toilet, toilet use, walking and locomotion and incontinence cares per previous two assessment tools. Toileting and incontinence care needs are unpredictable and unscheduled tasks over a 24 hour period of time. The plan did not document when and to what extent the patient requires assistance with activities of daily living (ADLs) and whether needed assistance can be scheduled or may occur at unpredictable times during the day and night. The patient's wandering and insomnia concerns had been referred to a psychiatric provider but this does not negate the patient's need for assistance in the overnight hours with incontinence cares, toileting, transfer toilet, walking and locomotion. 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.

Furthermore, medical necessity is defined as medical care and services that are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity or threaten some significant handicap. The requested Personal Care Aide (PCA) Level 2: Live-In Per Diem for 24 Hours per Day/7 Days per Week is medically necessary.