Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tardive akinesia, fall risk
Treatment: Personal care aide (PCA) level 2: 12 hours a day, 7 days per week, a total of 84 hours per week
The insurer denied Personal care aide (PCA) level 2: 12 hours a day, 7 days per week, a total of 84 hours per week.
The determination is overturned.

This is a female patient with a history of schizophrenia who has been on antipsychotics and developed tardive akinesia. She is at risk of falls. She lives alone and her brother lives next door and is very involved in her care. She is oriented to place and person but is very forgetful. She is able to verbalize her needs. She had no recent falls or hospitalizations. She has some informal support available from her brother who lives next door but she is mostly alone. I have reviewed the available records, the denial letters from the health plan, assessment/policy, personal care services support tool, Inter-Resident Assessment Instrument assessment (interRAI), external grievance review, plan of care summary, denial letters, demographics, and the patient's appeal letter. She is approved for 63 hours of personal assistant services (PAS) by the health plan, however, the patient is requesting 12 hours per day 7 days a week for a total of 84 hours of PAS and this is under review for medical necessity.

The services are medically necessary due to total dependance and the need for maximal assistance for most of the activities of daily living (ADL) and instrumental activities of daily living. She lives alone and is at risk of falls. She is not safe to be left alone for a number of hours.
She needs maximal assistance for meal preparation, managing medications shopping, bathing, dressing lower body, toileting, extensive assistance for locomotion, walking, dressing upper body, personal hygiene, bathing, transportation, and phone use. She is total dependence for managing finances. She has some informal support available from her brother who lives next door but she is mostly alone.

According to a study the need factors (ADLs and IADLs) were the most important predictors of hours of help. In all of the models examining paid and unpaid hours of help, bathing was the most important ADL measure in predicting hours, (as was required in this patient), controlling for other ADLs and IADLs for which help was received. Controlling for disability and other factors, age was of little importance. According to this study, the informal providers fail to provide as many hours of help to the people to meet their personal assistance needs [1]. PAS services typically fall under personal care, domestic services, paramedical services and paramedical services. Personal services included ambulation, bathing, dressing grooming, bathing, feeding etc., other services include cleaning, bedding, laundry, dusting etc., other related services include preparation of food, meal cleaning, menu planning, transportation, shopping, money management, etc. Paramedical services include administration of medications, bowel regimen, inserting a medical device into body orifices etc [2,3].
Based on my review, the patient needs help for a number of the above mentioned tasks and she lives alone. Her brother lives next door but is not present with her all the time. Some the required tasks especially the after hours tasks could not be helped by the family member. Per the office of disability employment policy, 2005, PAS could be provided both formally through paid personal assistant hired by a company, agency, or person with disability, and informally by a family member or a co-worker [4]. The patient has very limited informal support available. Per the United States Department of the Interior Office of The Secretary personal Bulletin N0. 17-18 (01/10/2018), a personal assistant provided is an employee or independent contractor whose primary job functions include provision of PAS [3]. Therefore, as she lives alone and need help with a maximum number of her tasks and has limited functionality, a total of 84 hours of PAS per week is medically necessary.