Appeal type: Medical necessity
Decision: Overturned

Issue: Increased PCA services
The health plan's denial is overturned in whole.
The increase in PCA hours is medically necessary for this patient.

The patient has a past medical history of severe depression, anxiety, psoriasis, polyarticular arthritis, hypertension, insomnia, lesion plantar nerve and vascular dementia who had been assigned 32 hours/week of PCA services, based on an assessment too. There was a request for increased PCA services and the patient had a new assessment tool performed. There was a change in the patient's cognition assessment from mild impairment to moderately to severely impaired. Tasks of meal preparation, ordinary housework, managing finances and shopping changed from maximum assistance to total assistance. There was an increase in assistance need for tasks of phone use, transportation, and equipment management from extensive to maximum between the two assessments. The task of eating increased from limited to extensive. There was no change in level of assistance of tasks of stairs, bathing, personal hygiene, dressing upper and lower body, walking, locomotion, transfer toilet and toilet use between assessments. The patient had a decreased level of assistance in task of bed mobility. The latest assessment noted the patient was unable to express self during questioning and was oriented x 1. The patient was not able to activate PERS or call 911. The patient needed reminders to eat and to take medication. The patient had an increase in wandering and hallucinations. The patient's child was no longer available during the day to provide care as a change in job schedule and increased family needs. The patient needed assistance to get on/off the toilet. There was a request for increased PCA services  by the patient's primary care physician (or provider) (PCP). The PCP provided a letter on the same date commenting the patient has chronic pain that severely affects her ability to walk, profound lack of motivation and trouble initiating and completing tasks and requested an increase in PCA services to 50 hours/week. There was a determination for an increase of PCA services from 32 hours/week to 35 hours/week. The PCP provided another letter  stating the patient has severe depression and requires constant prompting and redirection in order to perform ADL's and IADL's. The chronic pain has worsened, and patient requires increased assistance with walking. The PCP was recommending PCA services 10 hours/day, 5 days/week to total 50 hours per week.
The patient had an assessment tools performed. There was documentation of a change in cognitive level from a level 2/6 (mild) to 4/6 (moderate to severe) with an increase a need for assistance in multiple tasks. In addition, there is assistance needed for managing medication, the patient's child needs to manage and remind patient to take medications. The patient's cognitive ability caused a need for increased assistance with queuing for tasks of walking, locomotion, transfer toilet, toilet use and eating. The patient no longer had an informal helper, as the patient's child was no longer available during the day to provide care as a change in  job schedule occurred and increased family needs, and this was the main reason for the request of an increase in PCA service hours. The PCA services are not for supervision and safety alone as the patient requires prompting to successfully complete tasks.