Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paralysis
Treatment: Home Health Care
The health plan denied the requested increase in home health care hours. 
The health plan's determination is overturned.

The patient is a female with past medical history of paraplegia following a fall with a spinal cord injury, urinary incontinence, bowel incontinence, hypertension, hyperlipidemia, constipation, anxiety, and depression. She was hospitalized following a fall with subsequent rehabilitation stay and discharge to home. 24-hour care was recommended at discharge from rehabilitation. The patient had personal care assistance (PCA) services 8.5 hours/day, 7 days/week, to total 59.5 hours/week and there was a request to increase PCA hours to 24 hours/day, live-in, 7 days/week. The patient had a telephonic assessment tool performed, assessing the patient at total assistance with tasks of ordinary housework, stairs, transportation, dressing lower body, locomotion, and toilet use while maximum assistance with tasks of meal preparation, managing medication, shopping, bathing, and bed mobility. The patient was assessed at extensive assistance with tasks of managing finances, equipment management, personal hygiene, and dressing upper body while set up only with task of phone use. The patient was assessed as independent with eating. Overnight logs were provided noting the patient required a Hoyer lift for all transfers with repositioning every 4-5 hours overnight. The patient's health care advocate provided a letter stating the patient has medical conditions which necessitate the need for maximal to total dependence with activities of daily living (ADLs) . The letter further stated the recommendation for 24-hour care from her discharge from rehabilitation. The plan sent a final adverse determination denial notice stating the requested increase in PCA services was not medically necessary and the patient did not meet criteria. The patient's healthcare advocate provided a letter stating the plan did not address safety and maintenance of the patient's day and overnight needs and improperly used tasking tool for assignment of hours when unscheduled day and overnight needs exist.
At issue is the medical necessity of the requested increase in PCA hours.

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

Yes. The patient had a spinal cord injury with resultant paraplegia with extensive assistance needs. The patient's family had private aide services and PCA services following her rehabilitation stay. There was a request for increased PCA services. The patient has 24 hours care needs and the plan incorrectly used the assessment tool to calculate PCA hours. The patient has unscheduled and unpredictable care needs that span a continuum of time and there was not a plan to meet these care needs. The patient's care needs cannot be met solely with adaptive equipment and supplies. The patient has documented needs outside of the time that the PCA is available. Considering all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, consumer directed personal assistance (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 her own home.