Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus type 2.
Treatment: Home Health Care.
The health plan denied the requested increase in PCA hours. 
The health plan's determination is overturned.


The patient is a female with a past medical history of Sjogren's, diabetes mellitus type 2, coronary artery disease, hypertension, hyperlipidemia, history of CLL (Chronic Lymphocytic Leukemia), breast cancer, bladder incontinence, bowel incontinence, macular degeneration with legal blindness, glaucoma, osteoporosis, hearing loss, and pulmonary hypertension who was assigned 11 hours/day, 7 days/week to total 77 hours/week of PCA (Personal Care Assistance) services. The patient resided with her daughter for several months during the COVID-19 pandemic but planned to return to her home where she lives alone with a request to increase PCA services hours to 12 hours/day, 7 days/week to total 84 hour/week. The patient's daughter's home had stairs that were difficult for the patient to maneuver. The patient had an assessment tool performed assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, shopping, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, dressing upper body, walking, locomotion, transfer toilet, and toilet use while limited assistance with personal hygiene. With task of bed mobility and eating the patient was assessed as independent. The notes from assessment stated the patient lives alone and was requesting 24-hour live-in PCA services. The patient saw her primary care physician (PCP) on the same day with office note stating her medical diagnoses and that she is living with her daughter but planning to return home in the near future. The insurer sent final adverse determination denial notice stating service is not medically necessary and the patient did not meet criteria. The denial further stated the patient's care needs can be met by current services and the patient uses incontinence supplies to stay dry. In addition, the denial notice stated time is not provided when no tasks are being done for companionship or safety supervision. The plan further stated the hours can be split into morning and evening schedules to meet care needs better. The patient's PCP provided a letter requesting an additional hour of PCA services per day. The letter further notes the patient has incontinence and wears pull-up diapers at night and she is at high risk for a urinary tract infection (UTI) if she is left in her diaper for 13.5 hours each night. The patient is not able to get out of bed independently to use the bathroom, turn herself on her own at night or change her pull-up diaper. The PCP notes the patient is therefore at risk of developing dermatitis, skin tears and lesions, breakdown of skin tissue, and pressure ulcers which puts her at risk for serious risk infection.
At issue is the medical necessity of the requested increase in PCA hours.

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

Yes, the patient has multiple chronic medical problems and relies on PCA for all activities of daily living (ADLs) / instrumental activities of daily living (IADLs) . The patient has care needs that span 24-hour period of time due to unpredictable and unscheduled needs. The patient, her family, and her PCP have requested an additional hour of PCA services per day so that the patient's diaper was changed earlier in the morning after the overnight hours to prevent UTI and skin breakdown. The additional hour is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. 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.