Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure/CHF
Treatment: Home Health Care/Personal Care Aide Level 2: 12 hours per day-7 days per week; 12 hours per day-7 days per week (Split-Shift) - a total of 168 hours per week. 
The health plan denied the requested increase in Personal Care Aide Level 2: 12 hours per day-7 days per week; 12 hours per day-7 days per week (Split-Shift) - a total of 168 hours per week as not medically necessary. 
The health plan 's determination is upheld.

The patient is a female with a past medical history of dementia, congestive heart failure, bilateral hearing loss, hypertension, urinary incontinence, bowel incontinence, osteoarthritis, and atrial fibrillation who had been assigned personal care assistant (PCA) services 6 hours/day, 7 days/week, to total 42 hours/week based on assessment performed. This assessed the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, managing finances, stairs, shopping, bathing, dressing lower body, walking, locomotion, and transfer toilet. With tasks of transportation, personal hygiene, dressing upper body, toilet use, and bed mobility the patient was assessed at extensive assistance, while limited assistance with task of phone use. The patient was assessed at supervision with the task of eating. There was a request to increase PCA services and the patient underwent an assessment, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, and shopping while maximum assistance with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, toilet use, and bed mobility. The patient was assessed at extensive assistance with the task of eating and it was noted an activity did not occur for the ask of transfer toilet. Notes from the  assessment stated the patient had severely impaired cognition, had a decline in activities of daily living (ADL) status over the last 90 days, had deterioration of overall self-sufficiency in the last 90 days, and had a special diet with pureed foods. The patient's medical provider sent a letter stating the patient was homebound, confused, and hypokinetic and dependent on others for her daily living activities. The provider also noted the patient's medical conditions and mobility status had been rapidly deteriorating over recent time and the patient was unable to perform basic functions of living such as ambulation, bathing, dressing, and toileting without the assistance of a home aide. In addition, the provider noted the patient has nocturia and urinary incontinence which required assistance with the toilet day and night with history of multiple falls and it was the provider's opinion that a safe and appropriate health care regimen would be 24 hours/day, 7 days/week.

The health plan's determination of medical necessity is upheld, in whole.

No, Although there is documentation of increased assistance needs with multiple tasks when comparing the assessments, there is no documentation of the medical necessity of turning and repositioning every 2 hours in the overnight hours. In addition, there is no documentation or overnight logs specifically outlining the patient's care needs in the overnight hours. There is not documentation of care needs in the overnight hours that would not allow a PCA 5 hours of uninterrupted sleep. 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 12 hours per day-7 days per week; 12 hours per day-7 days per week (Split-Shift) - a total of 168 hours per week are not medically necessary for this patient.