Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Coronary Artery Disease (CAD)
Treatment: Home Health Care/Increase in Personal Care Worker Services to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week 

The health plan denied the requested Increase in Personal Care Worker Services to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week as not medically necessary. 
The health plan's determination is overturned.

This is a case review for a female with medical history notable for dementia, ischemic cardiomyopathy, heart failure with reduced ejection fraction, diabetes, end stage renal disease on hemodialysis, hypertension, hyperlipidemia, and anemia. She was receiving a total of 50 hours per week (6-8 hours per day, 7 days per week) of in-home Personal Care Worker (PCW) services. The patient's care team requested an increase in her hours to continuous care, 24 hours per day by more than one person. The insurance plan denied this request but did increase the PCW hours to 58 per week. This denial for continuous care is the subject under review.
A letter of support for this appeal was provided by the patient's internal medicine physician. The letter attests to her medical necessity for day and night personal care for assistance with activities of daily living (ADLs). Due to her frequent urinary and bowel incontinence, she requires frequent diaper changes to prevent skin breakdown. They also recommend frequent turning and positioning in bed to prevent skin wounds and to assist with fluid shifts and associated shortness of breath due to her heart failure. She is on diuretics for her heart failure which exacerbate the incontinence.

A Uniform Assessment System (UAS) was completed and was available for review. On functional assessment, the patient required maximal assistance for meal preparation, managing medications and managing finances. She requires total dependence for housework and shopping. For her ADLs, she requires maximal assistance for bathing, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper/lower body, and bed mobility. Functional status showed significant decline. She is completely incontinent of urine with no control present. She is occasionally incontinent of stool. A Mini-Mental Status Examination was conducted via telehealth. The result was 15, consistent with moderate dementia. The patient was noted to be alert and oriented x2 and is forgetful.

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

The requested health service/treatment of increase in personal care worker services to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week is medically necessary for this patient.
This patient has well documented personal health care needs. The UAS demonstrates that she is completely incontinent of urine and requires extensive assistance for all toileting and dressing needs. This problem is exacerbated by her diuretic use for congestive heart failure. She has had decline in her functional status with frequent hospitalizations. The patient's family has been filling in care gaps which really should be covered by personal care services.
The appealing physician is correct that if she does not receive increased personal care services, the patient is likely to suffer from medical decline. Failure to address diaper changes due to incontinence throughout the night would lead to skin breakdown and infections. Additionally, the physician is recommending turning and positioning in bed (which also requires assistance) to limit her chances of pressure ulcers. Turning and positioning is usually performed every 2 hours overnight and is a personal care service as defined by New York state law.