Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Above the knee amputation.
Treatment: Personal care worker (PCW) services 7 days per week, 24 hours per day; live in; 91 hours per week.
The insurer denied personal care worker (PCW) services 7 days per week, 24 hours per day; live in; 91 hours per week.
The determination is overturned.

The patient has a past medical history of coronary artery disease, osteoarthritis, hypertension, hyperlipidemia, chronic constipation, left above the knee amputation, history of stage 2 sacral ulcer, prostate cancer, cerebrovascular accident (CVA), peripheral artery disease (PAD), and congestive heart failure who had been assigned personal care assistant (PCA) services 6 hours/day, 7 days/week to total 42 hours/week based on an assessment performed assessing the patient at maximum assessment with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of bathing and dressing lower body. With the tasks of managing finances, managing medication, phone use, stairs, transportation, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating while independent with task of bed mobility.
The patient then had a phone assessment assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, bathing, and dressing lower body. With tasks of managing finances, managing medication, phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating the patient was assessed at limited assistance while independent with task of bed mobility. The patient was in a Skilled Nursing Facility (SNF). There was a plan to discharge the patient to home.
The insurer sent an initial adverse determination denial notice with a partial denial of request to increase PCA services to 24 hours/day, live-in, 7 days/week by increasing services to 8 hours/day, 7 days/week, to total 56 hours/week. The denial stated there were no unmet nighttime needs and the plan was not required to provide safety monitoring as a separate task on task based form. The plan acknowledged the request for appeal of the denial decision.
The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating PCA hours were not provided when the patient's needs can be met with adaptive or specialized equipment or supplies. The insurer also noted that the patient was in a SNF receiving treatment with no discharge date planned. The letter also stated the patient would remain in the facility with the potential for activities of daily living (ADL) and functional status improvement. The plan also recommended a home health aid and physical therapy (PT) upon discharge from the SNF as well as ongoing follow up with his primary care physician (or provider) (PCP). PT notes from the SNF indicated the patient required a Hoyer lift for transfers and was totally dependent on others for toileting. The insurer provided a case summary. The patient's niece provided a letter stating the patient had been in SNF since a fall, had multiple hospitalizations, was of extremely low weight and was not thriving. The niece also noted the patient required care in a nursing home due to living alone and recently becoming an amputee. In addition, the niece stated she and her cousin would tend to the patient's wellbeing and help him to ensure follow up care and treatment for prostate cancer which was not able to be done in the SNF. Lastly, the niece also stated the patient and the rest of the family believed the place the patient would benefit the most would be at home.
At issue is the medical necessity of personal care worker (PCW) services 7 days per week, 24 hours per day; live in; 91 hours per week.

Yes, the services are medically necessary.

The patient has 24 hour care needs as documented by the physical therapy notes from the SNF and therefore a task based assessment should not have been performed. The insurer did not update an assessment since the patient's admission to SNF and therefore, the last assessment underestimated the patient's care needs. The patient does not have informal help except occasionally with his nieces. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet the patient's unpredictable and unscheduled care needs. The patient's care needs cannot be met 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 24 hours/day, live-in, 7 days/week, to total 91 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.