Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease (CAD)
Treatment: Home Health Care-Personal Care Aid
The health plan denied an increase in personal care services.
The determination is overturned in whole. 

The patient is a male with a past medical history of coronary artery disease, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), bronchiectasis, and muscle weakness who had been assigned personal care aide (PCA) hours 4 hours/week. The patient had attended social daycare Monday through Friday 8 am to 1 pm prior to the coronavirus (Covid-19) pandemic. The patient lives with his wife.
There was a request to increase PCA services and the patient underwent telephonic assessment assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, stairs, and transportation. With tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance. The patient was assessed at supervision for task of managing medication and set up only with task of phone use while independent with tasks of bed mobility and eating. The patient lives with his spouse, but she is unable to care for the patient during the day due to her work schedule. The HELPS brain injury screening tool calculated 17 hours of PCA care per week for the patient.
The plan sent initial adverse determination denial notice stating the request to increase PCA services was not medically necessary and it was found the patient's current aide schedule can meet his functional needs.  
The denial stated the patient continued to need help with preparing meals, housekeeping, laundry, shopping, dressing, bathing, and personal hygiene. 
The patient saw his PCP with complaints of low back pain and right shoulder pain and physical therapy was recommended 2-3 times per week for four weeks for treatment. The plan provided additional information stating the patient is being monitored for medical conditions, is in stable condition, however, would benefit from physical therapy. 

The requested health service/treatment of an increase in personal care services from 4 hours a day, 2 days a week to 7 hours a day, 7 days a week is medically necessary for this patient.
The patient has progressive medical diagnoses of COPD and coronary artery disease with needed assistance with all tasks except bed mobility and eating. The patient's informal helper is not available during the day due to her work schedule. The patient had previously attended social adult day care but due to the pandemic this was stopped, and the patient was approved for social day care via telehealth. With social adult day care via telehealth the patient does not receive the assistance he needs with meal preparation, managing medication, personal hygiene, walking, locomotion, transferring to the toilet, and toilet use. The patient has unpredictable and unscheduled care needs during the time the patient's spouse is not available to provide informal help.
In summary, because the patient has assistance needs with walking, locomotion, transfer toilet, and toilet use outside of the hours his informal PCA is available and is unable to attend social adult daycare in person the patient requires an increase in PCA services. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)/Instrumental activities of daily living (IADL). 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 his own home.