Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 

The insurer denied increase in personal care hours to 38 per week. 
The denial is overturned. 

The patient is a female with past medical history of morbid obesity, vertigo, osteoarthritis, spinal stenosis, chronic kidney disease, anemia, low back pain, and urinary incontinence who had been assigned Personal Care Assistance (PCA) services 6 hours/day, 3 days/week to total 18 hours/week following telephonic assessment assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, shopping, and transportation. With tasks of managing finances, bathing, dressing lower body, walking, locomotion, and transfer toilet the patient was assessed at extensive assistance while limited assistance with tasks of managing medication, personal hygiene, and dressing upper body. The patient was assessed at supervision only for tasks of toilet use and bed mobility while independent with tasks of phone use and eating. There was a request to increase PCA services and the insurer sent initial adverse determination denial notice denying request to increase PCA services stating it was not medically necessary and the current PCA services were appropriately and safely meeting the patient's personal care needs. 

The assessment noted the patient's activities of daily living (ADL) status had declined in the last 90 days and she had deterioration of overall self-sufficiency in the last 90 days. The insurer sent final adverse determination denial notice denying request to increase PCA services stating patient has shower chair, shower grab bar, walker, and incontinence supplies to assist her needs and her personal care needs can continue to be met safely with her current PCA services. The denial also stated additional hours are not provided when tasks are not being performed. The subject under review is the medical necessity for personal care aide 38 hours per week. 

The health plan's determination is overturned. 

The personal care aide 10 hours per day, 3 days a week, 4 hours per day 2 days per week, for 38 hours per week is medically necessary. 

The patient's medical provider documented worsening functional status and medical necessity of increased PCA hours. The patient had increased assistance needs with tasks of phone use, bathing, personal hygiene, dressing upper/lower body, toilet use, and bed mobility when comparing assessments. Hence, the patient would need an increase in PCA services. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's unpredictable and unscheduled care needs. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADL/Instrumental activities of daily living (IADL). The patient's assistance needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 10 hours/day, 3 days/week, and 4 hours/day, 2 days/week to total 38 hours/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 her own home.