Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied increase in personal care assistance hours to 168 hours per week. 
The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, hyperlipidemia, coronary artery disease, bladder incontinence, hypothyroidism, history of transient ischemic attack (TIA), dementia, gastroesophageal reflux disease (GERD), dependence on supplemental oxygen, depression, constipation, osteoarthritis, and fecal urgency who had been assigned Personal Care Assistance (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week. The patient's primary care physician (PCP) provided a letter requesting an urgent increase in hours of home care due to rapidly deteriorating mental state, physical health, and functional status. The letter further stated the patient suffered from age-related physical debilities and had severe cognitive impairment due to vascular dementia with profound memory deficit. The patient had deficit of executive functioning, difficulty in reasoning, chronic insomnia with excessive motor activity during the nighttime, major depressive disorder with severe emotional lability, grossly limited range of motion with reduced mobility, severe debilitating pain secondary to hand osteoarthritis with complete loss of dexterity, right knee replacement, urinary and fecal incontinence for which she wears a diaper and requires multiple daytime and nighttime changes of soiled diapers and linens as to prevent skin irritation and rash, and ataxic gait with history of falling.  Lastly, the PCP letter stated, "I recommend and believe it is very important and medically necessary for [the patient] to have 2 split shifts of 12 hours of home care daily and nightly, 7 days/week to maintain her current health, and prevent her illness from progressing". 

The health plan's determination is overturned.

The patient has documented progressive medical conditions of dementia and osteoarthritis with underlying chronic medical problems of hypertension, coronary artery disease and transient ischemic attacks (TIAs). The patient is incontinent of bowel and bladder. The patient requires at least limited assistance with all activities of daily living (ADLs). The patient has unpredictable and unscheduled care needs that span a continuum of time. The patient requires assistance with walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient's medical provider has recommended turning and repositioning every 2 hours and prompt changing of soiled diapers as to prevent skin breakdown and infection. The patient also has medical condition of insomnia which caused her to require assistance with ADLs in the nighttime hours. The patient's care needs would not allow a personal care aide to obtain at least 5 hours of uninterrupted sleep. The patient's requested increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift 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.