Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Coronary Artery Disease (CAD).
Treatment: Home Health Care.

The health plan denied the requested increase in Personal Care Services to 43 hours per week as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a past medical history of obstructive sleep apnea, hypothyroidism, heart failure, back pain, hypertension, hyperlipidemia, coronary artery disease, arthritis. This review is regarding medical necessity of an increase in personal care services to 43 hours per week.
She had been assigned PCA (personal care assistant) services based on an assessment tool assessing the patient with modified independent cognition with no memory problems. She was noted to be alert and oriented, forgetful but able to reorient herself. She has no hearing difficulties and minimal vision difficulties. She was assessed total dependence with task of ordinary housework and maximal assistance with meal preparation. The patient was assessed at extensive assistance with task of bathing, personal hygiene, dressing upper body, dressing lower body, walking and locomotion, transfer toilet, toilet use and independent with bed mobility and supervision with eating. She is frequently bladder incontinent and bowel continent. A total of 22.6 PCA hours was assessed
The patient underwent a reassessment assessing the patient with modified independent cognition with no memory problems. She has no hearing difficulties or vision difficulties. She was assessed total dependence with task of ordinary housework and maximal assistance with meal preparation. The patient was assessed at extensive assistance with task of bathing, personal hygiene, dressing upper body, dressing lower body, walking and locomotion, limited assistance with transfer toilet, toilet use and independent with bed mobility and supervision with eating. She was noted with a decline in activities of daily living (ADL) status in the last 90 days, with decline in self-sufficiency. She is frequently bladder incontinent and bowel continent. A total of 31 PCA hours was assessed.
The patient's primary care physician wrote a medical necessity letter. The physician noted that the patient had multiple medical problems and requires assistance with activities of daily living (ADLs) and her limited range of motion renders her the need for assistance with removing her depends and bathing. She also requires prompting with hands on assistance for all of her care and she no longer resides with family. The physician recommends the provision of 10 hours, 7 days a week of assistance.
The patient was evaluated by her primary care physician. The physician noted that she had osteoarthritis of the shoulder which limits shoulder movements and tremors and will need assistance with ADLs and instrumental activities of daily living (IADLs) and changing pull ups after each episode of incontinence.
At issue is the medical necessity of the requested increase in personal care assistance hours to 43 hours per week.

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

The assessment tool indicated the patient had increased assistance needs with several tasks, including, housework, meal preparation, bathing, dressing upper/lower body, personal hygiene, locomotion. The patient is also incontinent, requiring the use of pull ups and she was also noted to have decreased shoulder mobility and tremors making it difficult for the patient to change these independently, thus will need assistance with every incontinence episode. She also has no informal helpers. The requested increase in assistance was not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 43 hours per week are medically necessary for this patient.