Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems / Congestive Heart Failure /CHF
Home Health Care

The patient is a female with past medical history of congestive heart failure, coronary artery disease, permanent pacemaker, vascular dementia, unstable gait, lower extremity weakness secondary to spinal stenosis and deconditioning, severe osteoarthritis of the lower extremities, urinary and stool incontinence, medication noncompliance, atrial fibrillation, leg edema, severe depression and panic attack who had been assigned personal care aide services of 8 hours/day, 7 days/week to total 56 hours per week. The patient had an assessment tool performed and comparison to the last assessment tool the patient improved in the tasks of meal preparation, shopping, dressing upper extremity, locomotion, walking, toilet use and toilet transfer. The patient had a decline in the tasks of eating and managing finances. The more recent assessment noted patient had moderately impaired cognitive skills with some difficulty performing simple multi step tasks without queuing. It was reported that the patient's memory was worse in the last 6 months. The assessment also stated patient was independent with sitting to lying, had unsteady gait, was dizzy, short of breath with exertion and had difficulty transferring from sitting to standing.
Following the most recent assessment the patient's personal care hours were decreased to 6 hours/day, 7 days/week to total 42 hours per week. The patient had an office visit with her primary care physician (PCP) noting severe difficulty walking, difficulty with changing position, could hardly take a few steps with walker/assistance, completely depends on home care aid, needs help with bathing, meal preparation, changing position and supervision of medication. The PCP wrote two letters following reduction in personal care aide services stating the patient was wheelchair bound, needed queues for incontinence cares due to skin problems and urinary tract infections (UTIs) and was forgetting to eat and required queues as reminder. The patient was having difficulty with medication management, requiring reminders as missing doses has led to worsening of congestive heart failure. The health plan denied request to keep personal care services at 8 hours/day, 7 days/week, 56 hours per week.

The health plan's determination is overturned.

Yes, personal care services, level 2, 8 hour/day, 7 days/week, 56 hours per week are medically necessary. The patient had documentation of worsening of her memory, more difficulty with medication management, personal hygiene, walking, locomotion and toilet transfer. The patient was having worsening of her medical conditions due to medication mismanagement. The patient was having skin issues and recurrent UTI related to personal hygiene and incontinence cares. The PCP noted patient was having severe difficulty with walking, couldn't change position to stand without help, hardly takes a few steps even with walker and assistance although assessment tool reported improvement in locomotion, walking and required limited assistance with personal hygiene. In summary, personal care services, level 2, 8 hours/day, 7 days/week to total 56 hours per week are medically necessary.