Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease, Congestive Heart Failure, Muscle Weakness, Mobility Issues.
Treatment: Personal Care Assistance Services: 12 Hours per Day, 7 Days per Week (Monday through Sunday) for a Total of 84 Hours per Week.
The insurer denied the Personal Care Assistance Services: 12 Hours per Day, 7 Days per Week (Monday through Sunday) for a Total of 84 Hours per Week.
The health plan's determination is overturned.

The patient is a male with a past medical history of dementia, depression, anxiety, urinary incontinence, chronic lower extremity edema, hypertension and atrial fibrillation on chronic anticoagulation. He also has a medical history of hypothyroidism, hyperlipidemia, benign prostatic hyperplasia (BPH), diabetes mellitus type 2, and osteoarthritis. The patient had been assigned personal care assistance (PCA) services 8 hours per day, 7 days per week. The patient's medical provider sent a letter to document the medical necessity of an increase in home health aide hours due to the patient's current medical conditions.

The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating the PCA hours provided under the patient's last authorization were still enough to meet his needs. The denial also stated safety supervision without the need for activity of daily living tasks is not required to be covered under the benefit plan. The patient's social worker and medical provider sent a letter requesting an immediate increase in more services including a necessary increase of home health aide services and also noting a referral for ongoing physical and occupational therapy had been made. 
The patient underwent an assessment assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, and transportation while extensive assistance was needed for the tasks of bathing, personal hygiene, dressing upper and lower body, walking, locomotion, toilet transfers, and toilet use. With task of phone use the patient was assessed at a supervision level while he was independent with the tasks of bed mobility and eating. 

The patient's medical provider sent a letter to document the medical necessity for an increase in current home health aide hours due to his current medical conditions. The letter stated the patient needed constant supervision and assistance with activities of daily living (ADL's) to avoid complications, exacerbation, and unnecessary hospitalization. 

The patient was taking medication late in the day for depression and the patient required more hands-on assistance for all ADL's and medication assistance. The patient's son provided a letter of appeal stating that the patient has had 3 falls in the past 6 months with 1 resulting in a rehabilitation facility stay.

There is documentation from the patient's medical provider of medical necessity for increased PCA services. The patient requires at least extensive assistance with walking, locomotion, toilet transfers, and toilet use. 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 requested health service and treatment of Personal Care Assistance Services: 12 Hours per Day, 7 Days per Week (Monday through Sunday) for a Total of 84 Hours per Week is medically necessary for the patient. There is documentation that the patient needs assistance with medication reminders outside of the currently assigned PCA services. The plan assumed that the patient had informal help outside of the currently assigned PCA services which is not the case. 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.