Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Home Health Care
The insurer denied an increase in Personal Care Aide (PCA) services.
The denial was overturned. 

The patient is a female with a past medical history of dementia, hypertension, diabetic neuropathy, osteoarthritis, urinary incontinence, and bowel incontinence. The patient had a fall. There was a request to increase Personal Care Aide (PCA) services and the patient underwent an assessment tool, assessing the patient at total assistance with meal preparation, ordinary housework, managing finances, stairs, and shopping while maximum assistance with tasks of managing medication, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. With tasks of phone use and eating the patient was assessed at extensive assistance.

The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's medical conditions, that the patient lived alone, and due to those circumstances, the patient would benefit from increasing hours of home care to assist with activities of daily living (ADLs).

The patient's psychiatrist provided a letter stating the patient's diagnosis of Alzheimer's disease. The letter stated the patient's health had been declining and the patient was unable to take care of herself. In addition, the letter stated the patient would benefit from more support and needed home health aide for 12 hours/day. There was an appeal of the denial decision with notes stating the patient has Alzheimer's dementia, lives alone, and is unable to cook, clean, dress, undress, take a shower, and reheat food.

At issue the medical necessity of Increase in Consumer Directed Personal Assistance Program (CDPAP) and PCA Level 2 to 12 hours per day, 7 days per week, for a total of 84 hours per week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of increase in CDPAP and PCA Level 2 to 12 hours per day, 7 days per week, for a total of 84 hours per week is medically necessary for this patient.

There is documentation of the patient's medical condition of Alzheimer's dementia with additional documentation of progression of her illness with decreased mental and functional capacity. The patient's psychiatrist and PCP have recommended an increase in home health hours. The patient lives alone and requires assistance with all ADLs and instrumental activities of daily living (IADLs). The patient had an increase in assistance needs with tasks of meal preparation, managing finances, phone use, and shopping. The patient has unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA hours is not solely for safety and supervision, but to assist the patient with safe completion of ADLs and IADLs.

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, CDPAP/PCA services 12 hours/day, 7 days/week, to total 84 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 her own home.

Therefore, the requested health service/treatment of increase in CDPAP and PCA Level 2 to 12 hours per day, 7 days per week, for a total of 84 hours per week is medically necessary.