Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Generalized osteoarthritis, seizures, Alzheimer's disease,  CHF (congestive heart failure), CAD (coronary artery disease), DM (diabetes mellitus), and asthma.
Treatment: Increase Personal Care Aide (PCA) Services 12 hours per day - 7 days per week For A Total Amount 84 Hours Per Week.
The insurer denied the Increase Personal Care Aide (PCA) Services 12 hours per day - 7 days per week For A Total Amount 84 Hours Per Week.
The denial is overturned.

The patient is a male. He has conditions including generalized osteoarthritis, seizures, Alzheimer's disease, CHF (congestive heart failure), CAD (coronary artery disease), DM (diabetes mellitus), and asthma.  He is appealing denial of increase from 35 PCA (personal care aide) hours per week to 84 hours per week.

The patient lives alone in a three-bedroom apartment.  He has support of daughter, son-in-law and his son.  He has a cane, shower grab bar, wheelchair, and bedside commode.  PERS (personal emergency response system) and adjustment of PCA (personal care aide) hours were refused by family.  Assessment performed shows minimally impaired cognitive skills with decline in decision making compared to 90 days prior and functional status: total dependence with housework, managing medications, shopping, and locomotion; extensive assistance with walking, toileting, and bed mobility; and maximal assistance with meal preparation, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing; and independent with eating.  Comparison of previous assessment performed  shows decline in functional status:  extensive assistance to maximal assistance with bathing and lower body dressing; limited assistance to extensive assistance with walking and toilet transfer; limited assistance to total dependence with locomotion; and independent to extensive assistance with toilet use and bed mobility. The previous assessment recommended 4 hours per day.  The patient was hospitalized with seizure.  Statement from NY (New York) ombudsman program recommends additional hours based on increased need with personal care services.   Statement from provider notes that wife used to take care of patient after home attendant left, but wife died.  The patient is at high risk of falling and needs a lot of help with ADLs (activities of daily living).  Statement from daughter notes that father was recovering from COVID and had a seizure.  Since discharge from hospital, he requires around-the-clock care. States 5 hours is no longer acceptable.

Yes, the Increase Personal Care Aide (PCA) Services 12 hours per day - 7 days per week For A Total Amount 84 Hours Per Week is medically necessary.
Medically necessary services are those which are:
1)safe 
2)effective
3)generally accepted national standard of medical practice 
4)not provided primarily for convenience of the patient or the practitioner 
5)the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient is appealing denial of 84 PCA hours per week.  Recent assessment approved 4 hours per day and most recent assessment approved 5.5 hours per day.  The most recent assessment shows decline in cognitive skills and the patient needs assistance with housework, managing medications, shopping, locomotion, walking, toileting, bed mobility, meal preparation, bathing, lower body dressing, personal hygiene, and upper body dressing.  This assessment shows significant decline in functional status with bathing, lower body dressing, walking, toilet transfer, locomotion; toilet use and bed mobility.  This decline occurred after death of spouse and hospitalization for COVID-related seizure.  The information provided shows a significant decline in the patient's functional status and he no longer has informal assistance from his wife who recently died.  He is only able to perform independently with eating and requires some level of assistance with all ADLs (activities of daily living) and personal care.  The proposed increase in PCA (personal care aide) to total 84 hours per week is medically necessary for this patient who requires assistance as noted above.