Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Arthritis
Treatment: Home Health Care-Personal Care Aide Services
The health plan denied the increase in personal care aide services as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This is a case review for an elderly female patient with medical history notable for arthritis. The patient is approved for 4 hours per day, 7 days per week (28 hours per week) of personal care aide services. The patient and her care team requested an increase to 8 hours per day, 7 days per week (56 hours per week) and the request was denied by the health plan. The attached documentation states that the denial was done on the basis of the patient having a mutual case with her husband. Her husband passed away two weeks later. The patient has had a significant decline in her condition since that time.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has chronic palpitations, hypertension, and shortness of breath. The physician states that the patient "has a very limited exertional capacity" and that she would "benefit from an increase in home health aide hours."
Another letter states that the patient has had several falls recently and that she requires aide support to ambulate with her walker. She needs assistance with ambulation, bathing, shopping, and food preparation. Due to the decline in her functional status, the physician requests additional home health hours to ensure adequate care.
Office visit notes were provided for review. The patient has had a functional decline since the loss of her spouse. She has had low energy and difficulty with mobility even with a walker.
Physical therapy notes were also provided for review. The patient was able to ambulate a maximum of 70 feet with a rollator walker and moderate human assistance. She required assistance for transfers to the bathtub and sit to stand transfers. She continues to receive physical therapy.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient lives in a one-bedroom apartment. She was alert and oriented with periods of forgetfulness. She is able to call for help in an emergency. For her instrumental activities of daily living (IADL's), the patient requires maximal assistance for meal preparation, housework, and shopping. She requires extensive assistance for transportation and stairs. For her activities of daily living (ADL's), the patient requires extensive assistance for bathing. She requires limited assistance for dressing, walking, locomotion, toilet transfer, and toilet use. She is independent for other domains. She is frequently incontinent of urine and continent of stool.

The requested health service of Personal Care Aide (PCA) services, 8 hrs. per day, 7 days per week is medically necessary for this patient.
The patient has had a documented functional decline since her UAS was performed. She now requires PCA assistance for ambulation and transfers. The health plan states that the patient can ambulate 70 feet, but she does require moderate assistance to complete this. Her condition has worsened and is no longer accurately reflected by the UAS. Her documented falls are evidence of unmet personal care needs. The modest requested increase to 8 hours per day is reasonable and medically necessary for the patient. Failure to provide for her personal care needs could result in additional falls and/or injury. The health plan's determination of medical necessity is overturned in whole.