Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis/Mobility Issues.
Treatment: Personal care assistance services, 24 hours per day 7 days per week (live-in).

The insurer denied Personal care assistance services, 24 hours per day 7 days per week (live-in).  The determination is overturned.

The patient has a past medical history of left leg below the knee amputation, age-related cognitive decline, atherosclerotic heart disease, lymphoma, benign prostatic hyperplasia (BPH), wheelchair dependence, heart failure, hyperlipidemia, depression, chronic ulcer of right foot, obesity, chronic pain, partial traumatic amputation of the right great toe, peripheral vascular disease, osteoarthritis, diabetes mellitus, and bowel incontinence, and urinary incontinence, who had been assigned personal care assistant (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week. There was a request to increase PCA services and the patient underwent a telephonic assessment assessing the patient at total assistance with ordinary housework, stairs, shopping, transportation, bathing, and toilet use while maximum assistance with tasks of meal preparation, managing finances, managing medication, equipment management, personal hygiene, dressing lower body, and locomotion. It was noted tasks of walking, transfer toilet, equipment management, and stairs did not occur during the telephonic assessment. The patient was assessed at extensive assistance with phone use, dressing upper body, bed mobility, and eating. Notes from the assessment stated the patient lived with his wife, had moderately impaired cognition, was alert and oriented x 1, was not felt to be a candidate for social day care (SDC) due to cognitive impairment/poor physical condition, required weight bearing assistance with all activities of daily living (ADLs), both daughters are employed full time outside of the home, and patient had a Hoyer lift in the home.

The patient's primary care physician (or provider) (PCP) provided a letter stating the patient suffered from many medical issues, had history of large B-cell lymphoma with treatment with chemotherapy, radiation, and bone marrow transplant, had diabetes with neuropathy, had an amputation of his left leg, and has osteomyelitis of his right foot. This letter also stated the patient required total assistance with his daily living activities including bathing, dressing, grooming, skin care, meal prep, toileting, cleaning after toileting, Hoyer lift transfers from bed to wheelchair and back, required prompting to take his medication, and had no informal support to provide him assistance with these care needs.

The patient's wife expired leaving the patient to live alone. The patient had a hospitalization for syncope and was diagnosed with coronovirus disease 2019 (COVID 19). The patient followed up with cardiology and was set up for an echocardiogram and Holter monitor. The insurer sent a final adverse determination denial notice denying request to increase PCA services to 24 hours/day, live-in, 7 days/week, stating the request was not medically necessary and the patient did not meet criteria. This denial stated the patient reported having some health issues; however, the change in his medical condition is not major, and the reported change does not impact the patient's current personal care needs. In addition the denial stated the patient or provider had asked for an increase in hours because of a decline in functional mobility due to osteomyelitis and a fall and the insurer recommended a follow-up with his doctor to see what is happening with his health. Lastly, the denial stated the current hours were enough to help with the patient's activities of daily living. Care logs were included for review. The patient required assistance with ADLs at least every 1 hour during the day and every 1-4 hours overnight. The patient's health care advocate provided a letter requesting an external appeal of denial of increased PCA hours. This letter noted the patient lived alone and was bedbound.

At issue is the medical necessity of personal care assistance services, 24 hours per day 7 days per week (live-in).

The services are medically necessary.

The patient had chronic progressive medical diagnoses of dementia, amputation status, peripheral vascular disease with documented worsening cognitive and functional status with request to increase PCA services. Since the time of his last assessment his wife expired and the patient had a hospitalization for COVID 19 with further decline in cognitive and functional status. The patient requires assistance with all ADLs/Instrumental activities of daily living (IADLs). The patient is bedbound/wheelchair bound and requires a Hoyer lift for transfers. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet those unscheduled and unpredictable care needs. The patient's care needs cannot be met with current PCA hours and/or adaptive equipment and/or medical supplies. The patient's family is not able to provide informal help outside of the patient's PCA hours due to their full time employment. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/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, Consumer Direct Personal Assistance Services (CDPAS) /PCA services 24 hours/day, live-in, 7 days/week, to total 168 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 his own home.