Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Coronary Artery Disease.
Treatment: Home Health Care.
The health plan denied the requested increase in personal care hours as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a past medical history of coronary artery disease, bipolar disorder, breast cancer, hypertension, hyperlipidemia, vascular neurocognitive disorder, Alzheimer's, spinal stenosis, arthritis, and degenerative disc disease. 
The patient's daughter requested an increase in services; thus, the patient underwent an assessment. She was assessed as with modified independence cognition and no memory problems. She has no hearing and vision difficulties. She requires total dependence with tasks of ordinary housework and meal preparation. She required maximum assistance with tasks of meal preparation and shopping. The patient was assessed at maximal assistance with the task of bathing, limited assistance with personal hygiene, extensive assistance with dressing upper and maximal assistance for lower body, extensive assistance with locomotion, extensive assistance with transfer toilet, toilet use, and bed mobility and limited assistance with eating. She was noted with a decline in Activities of Daily Living status in the last 90 days, with deterioration in self-sufficiency. She has frequent bladder incontinence and is infrequently incontinent with bowel. The Mini-Mental State Exam (MMSE) was administered with a score of 23. Based on the assessment an increase in services of 8 hours per day, 7 days a week, total of 56 hours per week were approved.
The patient's psychiatrist wrote a letter of medical necessity. She stated that the patient has a long history of psychiatric disease and subsequent hospitalizations. The patient had a rapid decline after a hospital admission and following the hospital stay, she has suffered from unstable mood and confusion. It was noted that she had a depressed mood, irritability, anxiety, and insomnia. She also has limited mobility and unstable balance and requires constant assistance with activities of daily living.
The patient's rheumatologist wrote a letter of medical necessity to support an increase in services to 24 hours a day due to the patient's sundowning and decreased mobility, stating that she is unable to be left alone at night due to high risk of falling.
The patient's primary care physician also noted that the patient requires assistance with all activities of daily living, as she requires hands-on assistance and cues, and her needs are unscheduled, thus requires 24-hour care.
At issue is the medical necessity of the requested increase in personal care assistant services.

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

No, the requested health service/treatment of an increase in personal care assistance (PCA) services- 7 days per week, 24 hours per day, live in is not medically necessary for this patient.
The patient requires assistance with ordinary housework, meal preparation, shopping, bathing, dressing, locomotion, and toilet use. At the assessment she was noted to need increased assistance with dressing and locomotion and hours were adjusted by the health plan to meet her needs. The patient appears to have medical equipment required including a wheelchair, shower chair, commode, and raised toilet seat. There is no documentation of loss of skin integrity requiring frequent position changes and the patient is infrequently incontinent of the bladder and is utilizing incontinence supplies as needed,
The patient does have progressive disease as evidenced by a recent hospital stay and fall, and problems with locomotion and confusion, however, there were no noted activities of daily living or instrumental activities of daily living that were requested that needed to be provided in the nocturnal hours, thus additional hours are not medically necessary.