Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Severe Asthma
Treatment: Home care/personal care HHC- level 2 personal care services per 15 minutes increase to 40 hours per week
The insurer denied home care/personal care HHC- level 2 personal care services per 15 minutes increase to 40 hours per week
The determination is overturned.

The patient has a past medical history of severe asthma, hypertension, hyperlipidemia, diabetes mellitus type 2, coronary artery disease, cervical cancer, chronic vertigo, osteoporosis, and varicose veins who had been assigned 20 hours of personal care assistant (PCA) services based on an assessment tool performed. The patient was assessed at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of transportation. She was assessed at limited assistance with the tasks of dressing lower body and set up assistance with tasks of managing finances, managing medication, and phone use. With the tasks of bathing, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating, the patient was assessed at independent.
The patient's primary care physician (PCP) provided a letter documenting medical necessity for increased home care hours. This letter also stated the patient's chronic medical conditions limit her ability to ambulate independently and because of her medical diagnoses the patient requires assistance with maintaining all activities of daily living. The PCP requested that the patient receive 8 hours of home care per day, 7 days/week in order to avoid exacerbation of her medical conditions and to ensure the maintenance of her medical and physical health.
The patient's daughter appealed the decision not to increase PCA hours by stating the patient needs to take medication regularly for her heart condition and requires prompting for this task. The insurer provided a final adverse determination notice stating denial of request to increase PCA service hours to 40 hours/week citing there was no significant change in medical conditions from the assessment tool to a monthly assessment call.
The patient's PCP provided Department of Health (DOH) form 4359 stating the patient has uncontrolled asthma, debilitating vertigo, often loses balance, and is unable to perform activities of daily living (ADLs). The patient's PCP provided a letter stating the patient's medical diagnoses and the medical necessity for need for increased home care hours. The letter further states the patient has several chronic medical conditions which limit her ability to ambulate independently, requiring assistance with maintaining all activities of daily living, including shopping, cooking, cleaning, maintaining personal hygiene, and attending medical appointments. The letter specifically recommends 8 hours of PCA service hours, 7 days/week. The provider appealed the insurer's adverse decision. The patient provided a letter to the insurer stating the patient's daughter provides 20 hours of PCA services per week. The daughter has to travel to take care of the patient. The daughter helps to prompt and remind the patient to take her medication. The daughter helps the patient to attend her medical appointments. The daughter also does household chores of cleaning, cooking, and shopping. It is a hardship for the daughter to provide assistance to the patient. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services per 15 minutes increase to 40 hours per week.

Yes, the requested services are medically necessary. The patient has a history of severe asthma and severe vertigo. The patient's provider states the medical necessity of increased PCA hours due to her underlying medical illnesses and limitation of performing ADLs. The patient's PCA service needs are underestimated by the assessment tool. The patient and the patient's PCP document that the patient needs assistance with walking, locomotion, transfer toilet and toilet use even though the assessment tool assessed the patient as independent. PCA 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.