Diagnosis: Chronic obstructive pulmonary disease (COPD)
Treatment: Personal Care Aide (PCA): 12 hours per day - 7 days per week - for a total of 84 hours per week
The insurer denied the Personal Care Aide (PCA): 12 hours per day - 7 days per week - for a total of 84 hours per week.
The denial is overturned.

The patient is a male with a with a past medical history of chronic obstructive pulmonary disease (COPD), oropharyngeal cancer and osteoarthritis who had been assigned personal care services.

The patient underwent assessment, he was assessed as maximal assistance with meal prep, total dependence with housework; maximal assistance with managing medications, maximal assistance with bathing, personal hygiene, dressing upper body, dressing lower body, walking, toileting transfers, maximal assistance with toilet use, maximal assistance with bed mobility and extensive assistance with eating. He is frequently incontinent with bladder and occasionally incontinent with bowel. It was noted that he has had worsening bladder and bowel incontinence. Activities of daily living (ADL) status in the last 90 days has declined, with deterioration in self-sufficiency. No falls in the last 90 days. He is on pureed diet with thickened liquids. He was noted with 2 small pressure ulcers in sacrum and buttock.
His physician wrote a letter of medical necessity stating that patient has been in the hospice program for laryngeal cancer and is hard of hearing. Physician stated that patient will benefit from an increase in aide services because he needs turning and positioning every 2 hours to avoid further skin breakdown and to assist with ADLs. The physician also stated that patient lives with an elderly friend who cannot provide sufficient assistance.

This review is for the medical necessity of request to increase in Personal Care Aide (PCA) services for a total of 84 hours per week.

The health plan's determination is overturned.

The requested service of increase in Personal Care Aide (PCA) services for a total of 84 hours per week is medically necessary for this patient. The patient requires maximum assistance to total dependence for all ADLs and instrumental activities of daily living (IADLs). The patient has had a decline in functional status as shown in the tasking tool, now requiring more hands on assistance for all tasks. The patient does not have readily available informal caregivers. Additionally, the patient has pressure ulcers and requires assistance with bed mobility, thus requiring frequent turning to prevent worsening of skin ulcers and to avoid development of new ulcers. Additional hours are medically necessary to enable the patient to remain in the community.