Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Disorders. 
Treatment: Home Health Care. 
The insurer denied of Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. 
The denial is overturned.

The patient is a female with past medical history of chronic obstructive pulmonary disease (COPD), urinary incontinence, heart failure, coronary artery disease, pulmonary embolism on anticoagulation, hyperlipidemia, frontotemporal dementia, and subdural hematoma who had been assigned Personal Care Assistance (PCA) services 4 hours/day, 5 days/week based on assessment performed via video teleconference assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, equipment management, walking, and locomotion while maximum assistance with tasks of phone use, bathing, dressing lower body, transfer toilet, and toilet use. With tasks of personal hygiene and dressing upper body the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating. Notes from the assessment stated the patient was residing in a nursing home. There was a request to increase PCA services and the patient underwent an in-person assessment assessing the patient at total assistance with all activities of daily living (ADL)/Instrumental activities of daily living (IADL) tasks. Notes from the assessment stated the patient was nonverbal, was unaware to eat and drink, could not summon help, had a decline in ADL status, and deterioration in overall self-sufficiency in the last 90 days. Client task sheet from the assessment estimated 10.5 hours/day of ADL/IADL assistance.

The health plan's determination is overturned.

The requested treatment is medically necessary. There is documentation of functional and cognitive decline as noted by the patient's medical provider, hospice social worker, patient's son, and in comparing the assessments. Because of the patient's functional decline and poor prognosis, she was placed on hospice. The patient requires total assistance with all ADLs and IADLs. The patient has care needs that span 24 hours and a task based tool should not have been utilized by the insurer. The patient is not able to summon help or express needs. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient does not have informal help outside of assigned PCA services. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with medical supplies and adaptive equipment. The patient's overnight care needs related to assisting with ADLs would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 x 12 hours, split-shift, 7 days/week, to total 168 hours/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.