Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System 
Treatment: Home Health Care 
The insurer denied increase in personal care hours to 7 days x 24 hours (continuous service) per week. 
The denial is upheld.

The patient is a female with past medical history of hypertension, coronary artery disease (CAD), hypothyroidism, hyperlipidemia, congestive heart failure (CHF), oxygen dependent chronic obstructive pulmonary disease (COPD), osteoporosis, osteoarthritis, status/post (s/p) Covid-19 infection, dementia, urinary incontinence, and anxiety who had been assigned personal care assistance (PCA) service hours 9 hours/day, 7 days/week, to total 63 hours/week following assessment performed. The patient was assessed at total assistance with tasks of ordinary housework and shopping while maximum assistance with tasks of meal preparation and bathing. With tasks of managing finances, managing medication, phone use, stairs, transportation, personal hygiene, dressing lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with task of eating. The patient was assessed as independent with task of bed mobility. Notes from the assessment stated the patient was minimally impaired cognitively.

The insurer sent final adverse determination denial notice denying request to increase PCA services to 24 hours/day, split shift, 7 days/week and continuing to approve 24 hours/day, live-in, 7 days/week. The denial also stated live-in, 24-hour personal care services are the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and repositioning, or feeding and whose need for assistant is sufficiently infrequent that the live-in, 24-hour personal care aide would be able to provide the required care. The insurer also confirmed in the social work notes that the patient's home had the capacity to accommodate a live-in aide. In addition, the denial also stated there was no documentation of the patient having a hospital bed, alternating air pressure or gel mattress, or commode which could be used safely to meet the patient's bed mobility and toileting needs.

The health plan's determination is upheld.

No, the requested increase in personal care assistant hours to 7 days x 24 hours (continuous service) per week is not medically necessary for this patient. Following an assessment done, the insurer approved PCA services 24 hours/day, live-in, 7 days/week. There is no documentation of medical necessity for split-shift PCA services in the accompanying records or the letter from the patient's primary care physician (PCP). There is no documentation of a medical reason or need for frequent turning and repositioning every 2 hours. There is no documentation of the need for frequent toileting and incontinence cares. There is no documentation that a personal care aide would not be able to obtain at least 5 hours of uninterrupted sleep. The patient has not obtained durable medical equipment (DME) such as hospital bed and gel mattress which would help assist patient with certain activities of daily living (ADL) tasks. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested increase in hours is not medically necessary for this patient.