Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System.
Treatment: Home Health care.
The insurer denied 7 days x (2) 12 hour split shits personal care assistance.
The denial is overturned.

The patient is a female with past medical history of oxygen dependent chronic obstructive pulmonary disease (COPD), coronary artery disease, congestive heart failure, venous thromboembolic disease, chronic anticoagulation, gait abnormality, severe knee osteoarthritis, and polymyalgia rheumatica who had previously been assigned Personal Care Assistance (PCA) services 32 hours/week. The patient had a telephonic assessment tool performed, assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of managing finances, managing money, stairs, transportation, equipment management, bathing, dressing lower body, transfer toilet, and toilet use while limited assistance with tasks of dressing upper body, walking, and locomotion. With task of phone use the patient was assessed at set up only and independent with tasks of personal hygiene, bed mobility and eating. Notes from the assessment stated the patient lived alone, had 32 hours of PCA services and private pay PCA services overnight. This assessment also stated the patient used a walker in the home and a wheelchair when out of the home. The insurer sent initial adverse determination denial notice denying request to increase PCA services to 24 hours/day but approving PCA services at 7 hours/day, 7 days/week, to total 49 hours/week. 

The health plan's determination is overturned.

The requested Personal Care Aide 7 days x (2) 12 hour split shifts is medically necessary for this patient. The patient has documented chronic and progressive medical conditions of severe knee osteoarthritis and oxygen dependent COPD. The patient has at least limited assistance needs with all instrumental activities of daily living (IADLs) and activities of daily living (ADLs), except for bed mobility and eating. The patient has documented nighttime needs of walking, locomotion, and toileting throughout the night that would not allow a live-in personal care aide to obtain at least 5 hours of uninterrupted sleep. The patient should not be forced to utilize pull-ups as a means for toileting when she is continent of urine. The patient has, as above, unscheduled and unpredictable care needs that span a continuum of time. As the patient does have 24-hour care needs, the plan should not utilize a task assessment tool in determining PCA hours. The patient's care needs cannot be met with assigned PCA hours and/or adaptive equipment and/or medical supplies. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs/IADLs. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 7 days x (2) 12 hour split shifts 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.