Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent Falls. 
Treatment: Home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in). 

The insurer denied home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in). 
The determination is overturned. 

The patient has a past medical history of coronary artery disease, anxiety, depression, osteoarthritis, urinary incontinence, history of deep vein thrombosis (DVT), venous insufficiency, diastolic heart failure, hypertension, poor memory, and recurrent falls who had been assigned personal care assistant (PCA) services 42 hours a week based on an assessment performed telephonically assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, and shopping while extensive assistance with the tasks of managing finances, managing medication, phone use, stairs, transportation, bathing, and dressing lower body. With the tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance while independent with the tasks of bed mobility and eating. 

The patient had a hospital admission for hyponatremia with subsequent transfer to rehabilitation with a request to increase PCA services and the patient underwent another assessment assessing the patient at total assistance with ordinary housework while maximum assistance with the tasks of meal preparation, managing medication, and shopping. The patient was assessed at extensive assistance with the tasks of managing finances, stairs, bathing, and dressing lower body while limited assistance with the tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility. With the task of eating the patient was assessed at independent. Notes from the assessment noted the patient resided at a Skilled Nursing Facility (SNF) and was able to use a wheelchair independently. 

The insurer sent an initial adverse determination denial notice denying the request to increase PCA services to 24 hours/day, live-in, 7 days/week stating the request was not medically necessary and the assessment done showed no change in activities of daily living within the last 90 days and no change in overall self-sufficiency. The denial also stated there has been no change in the patient's social circumstance and she had the support of her family. 
The patient provided a letter stating that when her aide left at 5 PM she was not able to walk by herself to use the bathroom safely, get dressed or undress by herself, or make herself a meal. The patient's letter also stated she was not stable when walking or standing which has resulted in many falls when she is alone. In addition, the letter from the patient stated she was reliant on her walker and home attendant to be next to her when standing or walking. The patient also noted at night she was not able to get out of bed even to use the chair basin next to her. She reported a fall a few months ago when attempting to get out of bed and use the bedside commode. The patient noted she was scared to stand up by herself after her aide leaves. Lastly, the patient stated her family support was very limited as they did not live near her and she was requesting a home attendant for 24 hours/day, 7 days/week to ensure that she is safe and has the assistance she needs with her daily and nightly activities. 

The patient's primary care physician (or provider) (PCP) provided a letter stating an increase in personal care services was medically necessary for the patient. The letter also stated that in order to meet all of the patient's personal needs, he recommended an increase in home health services to 12 hours/day, 7 days/week. The provider also noted the patient was physically and mentally getting worse and her falls have resulted in rib fractures, knee injuries, and skin tears. The provider also noted the patient lived alone and had no formal or informal support to provide her assistance with her personal care needs. The insurer provided a final adverse determination denial notice denying the request to increase PCA services. The denial stated there was no letter of medical necessity provided in the appeal and based on the 2 nursing assessments the patient was self directing, had decrease in function, and was now needing more assistance with medication management and housework. The denial also noted it was medically necessary to continue to provide the patient with 42 hours of care per week as she did not have significant nightly needs that will require a 24-hour live-in personal care aide. The patient's physician appealed the denial decision. 

At issue is the medical necessity of home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in). 

Yes, the requested services are medically necessary. 
There is documentation from the patient herself and the patient's physician of a decline in functional mobility following her hospitalization and subsequent rehabilitation stay. There is also documentation of multiple falls and injuries when the patient has tried to ambulate and transfer on her own. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use. 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 requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The insurer incorrectly assumed that the patient had informal help outside of the 42 hours/week of PCA services. 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, live-in, 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 her own home.