Appeal type: Medical necessity
Decision: Overturned

Diagnosis: rheumatoid arthritis
Treatment: Personal care assistant
The insurer denied Personal Care Assistance Services: 24 Hours per Day (Live-In), 7 Days per Week. The health plan's determination is overturned.

The patient is a female with past medical history of rheumatoid arthritis with severe hand deformity, urinary incontinence, bowel incontinence, oxygen dependent chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia, hypothyroidism, atrial fibrillation, and lung cancer who had been assigned PCA (personal care assistant) services based on assessment tool performed via telephone that assessed the patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of managing finances, stairs, shopping, and equipment management. The patient was assessed at extensive assistance with tasks of managing medication, transportation, bathing, and dressing upper/lower body while limited assistance with tasks of personal hygiene, walking, locomotion, transfer toilet, and bed mobility. With tasks of phone use and toilet use, the patient was assessed at supervision. Notes stated the patient had no informal helper. The patient was hospitalized recently with atrial fibrillation and shortness of breath and was diagnosed with lung cancer. Overnight log noted the patient required assistance 4 times from 8:30 pm to 4:00 am. There was a request to increase PCA hours.

Personal Care Assistance Services: 24 Hours per Day (Live-In), 7 Days per Week - Monday through Sunday are medically necessary for this patient. 
The patient has documented chronic and progressive medical diagnoses of COPD, lung cancer, and rheumatoid arthritis. Because of her age, there was no plan for treatment of the patient's lung cancer recently diagnosed during hospitalization. The patient has marked deformity of both of her hands from rheumatoid arthritis for which the health plan underestimated her care needs with bathing, personal hygiene, dressing upper/lower body, toilet use, and eating. Notes from the recent assessment documented a decline in overall self-sufficiency. In addition, notes from the assessment also noted patient had a pressure ulcer of the sacrum and required turn and reposition every 2 hours. The patient requires at least limited assistance with all activities of daily living (ADL)/ Instrumental activities of daily living (IADL). The patient has no informal helper. The patient has unscheduled and unpredictable care needs that spanned a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's current PCA hours and/or adaptive equipment and/or/medical supplies are not sufficient to meet the patient's care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/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, Personal Care Assistance Services: 24 Hours per Day (Live-In), 7 Days per Week - Monday through Sunday 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.