This is a patient with a past medical history of Parkinson's disease, osteoarthritis, low back pain and complications from a right knee replacement. The patient required right total knee replacement revision surgery due to disruption of her initial surgery because of a fall. She was hospitalized for this procedure. She had an assessment tool performed for Personal Care Assistant (PCA) services. She was assigned 7.5 hours/day, 7 days/week to total 52.5 hours per week. The patient had another fall while trying to ambulate alone and had a dislocation of patella of the right knee and was placed in a knee immobilizer. The patient's primary care provider (PCP) requested an increase in PCA service hours to 12 hours/day, 7 days/week to total 84 hours per week. The patient had an assessment tool performed with no change in status of any of her activity needs assessment. There was an initial adverse determination notice of non-approval of increase in PCA services. There was a letter from the health plan of final determination of the denial for 12 hours/day, 7 days/week to total 84 hours/week. The patient's orthopedic provider recommended an increase in PCA service hours to 24 hours per day to aid the patient with ambulation, locomotion and toilet transfer. At a visit with orthopedics, it was again recommended that the patient apply for an increase in hours for PCA services due to her risk of falling and further injury with tasks in her home. At issue is the medical necessity of an increase in PCA services.
The health plan's determination is overturned. The increase in consumer directed personal assistance program services: 12 hours per day, 7 days per week for a total of 84 hours a week is medically necessary. The patient has a history of osteoarthritis and had a right knee replacement. After this surgery the patient had a fall while trying to ambulate and needed to have revision of her right knee replacement. The patient had another fall with the complication of a dislocation of the right knee that had previous replacement and revision. The patient did not have a change in her assessment tool although the patient had more difficulty in her ability to ambulate, walk and transfer from the toilet. The PCP and orthopedic provider felt it was medically necessary for an increase in PCA hours, with the PCP requesting 12 hours/day, 7 days/week and the orthopedist requesting 24 hour/day, 7 days/week. The patient did live with her daughter, but her daughter works and could not provide informal care outside of the recommended PCA service hours recommended by the health plan.