Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Coronary Artery Disease
Treatment: Home Health Care
The health plan denied the requested increase in personal care hours as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with past medical history of dementia, urinary incontinence, bowel incontinence, coronary artery disease, and abnormalities of gait and mobility who had been assigned personal care assistant (PCA) services 7 hours/day, 7 days/week, to total 49 hours/week. This was based on assessment performed, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, bathing, personal hygiene, dressing upper/lower body, and toilet use. With tasks of stairs, transportation, walking, locomotion, transfer toilet, and bed mobility; the patient was assessed at extensive assistance, while independent with task of eating.  There was a request to increase PCA services and the patient underwent another assessment, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, and transportation while maximum assistance with tasks of phone use, bathing, personal hygiene, dressing lower body, toilet use, and bed mobility. With tasks of dressing upper body, walking, locomotion, and transfer toilet, the patient was assessed at extensive assistance while supervision with the task of eating. The patient's primary care physician (PCP) provided a letter stating the patient had advanced dementia and was incapable of performing any tasks and was a danger if left alone. 

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

Yes. There is documentation of the patient's worsening cognitive and physical functioning. The patient previously had assistance from her husband who passed. The family was paying for overnight assistance but were unable to continue due to financial constraints. The daughters lived an hour away. The patient required at least extensive assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient has care needs in the overnight hours that would not allow a personal care aide at least 5 hours of uninterrupted sleep. The insurer reported in their denial the patient had care needs that were outside of the scope of a PCA however there was no documentation in either assessment nor in her medical providers letter documenting assistance needs outside of the scope of a personal care aide. 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, PCA services 12 hours/day, 7 days/week, 12 hours/day, 7 days/week, split-shift, 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 her own home.