Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory. 
Treatment: Home Health Care. 
The insurer denied Personal Care Assistance 24 hours a day 7 days a week live-in. 
The denial is overturned.

The patient is a female with past medical history of hypertension, chronic kidney disease, congestive heart failure, atrial fibrillation on long term anticoagulant, dementia, gout, chronic obstructive pulmonary disease (COPD), aortic valve disease, permanent pacemaker, and urinary incontinence who had been assigned Personal Care Assistance (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week following request. The patient was hospitalized following a fall with diagnosis of inferior/superior pubic rami fractures with subsequent transfer to rehabilitation facility. Patient was hospitalized two times during rehabilitation stay, once for COPD exacerbation and again for pneumonia. The patient required supplemental oxygen following these hospitalizations.

The health plan issued a final adverse determination denial notice denying request to increase PCA services stating the request is not medically necessary and does not meet criteria. The denial noted recommendation to continue physical therapy (PT)/occupational therapy (OT) at home to increase the patient's safety. The plan further stated the patient has comprehensive medical services in rehabilitation and the patient is not safe at home, also noting the patient's daughter has reported the patient cannot be left alone and this is a life and death situation. The decision was appealed. 

The subject under review is the medical necessity for Personal Care Services 24 hours per day, 7 days per week live-in.

The health plan's determination is overturned.

The requested Personal Care services, 24 hours per day, 7 days per week live-in is medically necessary for this patient.

The patient is a female with chronic and progressive chronic medical diagnoses who was hospitalized following a fall with subsequent re-hospitalization twice for COPD and pneumonia. The patient was placed on supplemental oxygen. The patient does not have an informal helper. The patient's telephonic assessment underestimated her care needs as the PT/OT notes from rehabilitation the next day documented an increased needs in assistance with tasks of bathing, personal hygiene, toilet use, and bed mobility compared to the assessed levels on the telephonic assessment. The patient requires assistance with all activities of daily living (ADLs)/Instrumental activities of daily living (IADLs). The patient has unscheduled and unpredictable care needs that span a continuum of time. An increase in PCA service hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Given the patient's rehabilitation care plan, it was felt the patient was safe to return to home with PCA services. Given the plans clinical standards, all information provided regarding the patient, the attending physician's statement, and the applicable and generally accepted practice guidelines an PCA services, 24 hours/day, live-in, 7 days/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.