Dx: Orthopedic/Musculoskeletal
Tx: Home Health Services
Denied: Home health Services (increase in hours)
Denial: Overturned in whole

The patient is a female with a past medical history of osteoarthritis, coronary artery disease, hypertension, gastroesophageal reflux disease (GERD), hypothyroidism, hyperlipidemia and urinary incontinence who had been approved for personal care aide (PCA) services 24 hours live-in/day, 7 days/week. The patient's family requested to decrease PCA services to 24 hours live-in/day, 3 days per week with a new private aide the other 4 days per week. The patient had assessment tool done on 5/1/19 and on 11/26/19 without any change in her activities of daily living (ADL) and Instrumental activities of daily living (IADL) needs. The aide was no longer available due to health issues and on 1/9/20 the family requested to have PCA services increased to 24 hours per day live-in per diem 6 days per week. The insurer denied this request.
The subject under review is the medical necessity for the change in hours.

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

Yes, the requested service of personal care aide level 2 services (24 hours per day-live in per diem, 6 days per week) is medically necessary for this patient.
The patient had been previously assigned PCA services 24 hour live-in/day, 7 days/week and the patient's family requested a decrease in services as they were able to make other arrangements. The arrangement of a private live-in aide was unable to be continued and the family and they requested to have PCA services provided to the patient similar to before except they were able to provide one day of 24 hour coverage, hence requesting PCA services 24 hour live-in per day, 6 days per week. The patient had previously qualified for services 24 hours/day, 7 days/week with assessment done in the spring and at her assessment in the fall did not have any change in her level of assistance, therefore qualifying the for the same, previous level of PCA services (although current request was for 6 days/week instead of 7 days/week).