Appeal type: Medical necessity
Decision: Overturned

Orthopedic/musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide (PCA) Level 2 Services
The insurer denied an Increase in Personal Care Aide (PCA) Level 2 Services: 6 Hours per Day, 5 Days per Week (Total of 30 Hours per Week). The health plan's determination is overturned. 

The patient is a male with past medical history of hypertension, osteoarthritis, osteoporosis, coronary artery disease, hyperlipidemia, benign prostatic hypertrophy, deep venous thrombosis, anemia, carotid artery disease, goiter, bladder incontinence, and vitamin D deficiency who was assigned PCA (personal care aide) services based on assessment tool performed. The patient was assessed at total assistance with task of ordinary housework and maximum assistance with tasks of meal preparation, stairs, shopping, and transportation. The patient was assessed at extensive assistance with tasks of managing medication, bathing, dressing lower body, walking, locomotion, and transfer toilet and limited assistance with tasks of managing finances, personal hygiene, and dressing upper body. With tasks of bed mobility the patient was assessed at supervision, set up only for task of phone use, and independent with task of eating. There was a request to increase PCA hours to 6 hours/day, 5 days/week, to total 30 hours/week. The patient had a telephonic assessment tool performed assessing the patient at total assistance with task of ordinary housework and maximum assistance with tasks of meal preparation, managing medication, stairs, and shopping. The patient was assessed at extensive assistance with tasks of transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet and limited assistance with tasks of managing finances, personal hygiene, and dressing upper body. With tasks of toilet use, bed mobility, and eating the patient was assessed as independent. 

The Increase in Personal Care Aide (PCA) Level 2 Services: 6 Hours per Day, 5 Days per Week (Total of 30 Hours per Week) was medically necessary.
The patient has progressive medical conditions of osteoarthritis making it more difficult to participate in activities of daily living (ADLs). The patient's assessment noted the patient had deterioration in his physical functioning as a reason for new assessment. The assessment also noted the patient needed assistance with tasks of personal hygiene, incontinence cares, transfer toilet, walking, and locomotion which occur at unpredictable and unscheduled times, therefore, the patient would need PCA services outside of the time he has informal/formal helper. The plan did not document the nature of the patient's informal help or how the patient's unscheduled and unpredictable needs would be met when the patient was alone. The increase in PCA service hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/Instrumental activities of daily living (IADLs) 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 6 hours/day, 5days/week, to total 30 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 his own home.