Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home health care (HHC) level 2 personal care services (PCS) increase to 24 hours/day (split-shift)
The insurer denied HHC level 2 PCS increase to 24 hours/day (split-shift).
The determination is overturned.

The patient has a past medical history of benign prostatic hyperplasia (BPH), coronary artery disease, ischemic cardiomyopathy, congestive heart failure, hypertension, hypothyroidism, dementia, gastroesophageal reflux disease (GERD), hyperlipidemia, paroxysmal atrial fibrillation (afib), frequent falls, urinary frequency with incontinence, chronic dizziness, and edema. The patient saw his primary care physician (or provider) (PCP), noting the patient had a fall with a head injury. The patient had fall with injuries. The patient saw his PCP noting that the patient recently had a coronavirus (COVID) infection and received an antibody infusion.

The PCP documented a phone call noting that the patient had a mechanical fall and hit his head on the counter. Emergency Medical Services (EMS) were called, but the patient was not taken to the hospital. There was another phone call noting the patient was more confused and given the recent fall, he was set up for a computed tomography (CT) scan of the head which was unremarkable. A urine culture was sent. There was a request to increase personal care assistant (PCA) services and the patient had an assessment assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, stairs, shopping, and transportation while extensive assistance with the tasks of managing finances, managing medication, and phone use. The patient was assessed at limited assistance with the tasks of bathing and dressing upper/lower body while independent with the tasks of personal hygiene, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The patient was assigned PCA services 5 hours/day, 7 days/week, to total 35 hours/week.

The patient was hospitalized with pneumonia and congestive heart failure (CHF) and subsequently transferred to rehabilitation. A discharge summary from rehabilitation noted that the patient required the physical help of 1 person with transfers, bed mobility, walking, stairs, and dressing lower body while balance/guidance help with toileting and upper body activities of daily living (ADLs).

There was a request to increase PCA services and the patient underwent an assessment tool assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance with the tasks of stairs and transportation. With the tasks of managing finances and managing medication, the patient was assessed at extensive assistance while limited assistance with the tasks of phone use, equipment management, bathing, dressing lower body, walking, locomotion, and transfer toilet while supervision with task of eating and independent with the tasks of personal hygiene, dressing upper body, toilet use, and bed mobility. Notes from the assessment indicated that the patient had a hospital bed, lived with his spouse, and had an open heel wound that was being addressed by a certified home health agency nurse.
The patient saw the PCP noting for the past several weeks that the patient had decreased oral intake with periods of confusion noting an overall deterioration in his condition.

The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating the patient had no loss of motor function, that the recent assessment did not demonstrate changes with most of his physical functioning since the prior assessment, that the personal-care hours currently authorized were in the amount, duration, and scope necessary to meet the patient's care needs, and safety monitoring was not a covered benefit under the personal care services program.

The patient/family appealed denial decision. The patient's PCP appealed the denial decision. The patient's healthcare advocate provided a letter outlining the patient's past medical history, physical therapy (PT) notes from rehabilitation stating the patient had decreased functional capacity, decreased dynamic balance, decreased static balance, deficit in judgment, deficit in proprioceptive abilities, and decreased safety awareness, had fallen 4 times, was at high risk for bleeding because of low platelets and anticoagulant use, needed assistance to stand up from the wheelchair, was unable to remain standing on his own without assistance, reported occupational therapy (OT) and PT notes from rehabilitation noted the patient requires maximum assistance with supine to sit position transfers, bed mobility, dressing upper body, hygiene, and self-feeding and was totally dependent on assistance with changing position from sitting to standing and walking.

The patient's PCP provided a letter stating over the past year the patient had clinically declined and more importantly after recent hospitalization was completely deconditioned and required assistance from a caregiver full-time, during the day and night. The provider noted the patient required assistance with all of his ADLs including but not limited to bathing, toileting, transferring, walking, dressing, food preparation, and grooming. In addition, the provider noted it was important that his caregiver stay awake and alert during the day and night to assist him with transfers and toileting since he urinates frequently due to the use of diuretics and history of underlying BPH. The provider noted this assistant would help to decrease his chance of falling as he is at high risk for falls and hospitalization and he is on blood thinners.

At issue is the medical necessity of home health care (HHC) level 2 personal care services (PCS) increase to 24 hours per day (split-shift). 

Yes, the services are medically necessary.

There is documentation from rehabilitation and the patient's PCP noting a decline in cognitive and functional ability following hospitalization. There are specific records from PT and OT from rehabilitation stating the patient's care needs with ADLs and instrumental activities of daily living (IADLs) and when comparing to the assessment, underestimated the patient's care needs with multiple ADLs. Notes from the assessment indicate the patient has an open heel blister requiring frequent turning and positioning to prevent further skin breakdown. The patient has BPH and is on a diuretic causing him to urinate frequently. The patient requires at least limited assistance with walking, locomotion, and transfer toilet. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs in the overnight hours would not allow a PCA 5 hours of uninterrupted sleep. The patient's care needs are 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. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split shift, 7 days/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 his own home.