Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory Problems/Arrhythmia/Irregular Heart Rhythm
Home Health Care

Diagnosis: Cardiac Arrhythmia.
Treatment Home Health Care.
The health plan denied the requested increase in home health services. 
The health plan's determination is overturned.

The patient is a female with a past medical history of severe glaucoma, severe macular degeneration, diabetes mellitus type 2 with retinopathy, history of central retinal vein occlusion, hypertension, osteoarthritis, permanent pacemaker, congestive heart failure, hyperlipidemia, history of methicillin-resistant staphylococcus aureus (MRSA), and urinary incontinence who had been assigned Consumer Directed Personal Assistance (CDPAS) services 4 hours/day, 6 days/week, to total 24 hours/week based on assessment tool. The patient was assessed at total assistance with the task of shopping, while maximum assistance with task of ordinary housework. The patient was assessed at extensive assistance with tasks of bathing and dressing lower body while limited assistance with tasks of managing finances, managing medication, and transportation. With tasks of meal preparation, stairs, walking, locomotion, and transfer toilet, the patient was assessed at supervision, while set up only with task of phone use. With tasks of personal hygiene, dressing upper body, toilet use, bed mobility, and eating the patient was assessed as independent. The client task sheet calculated 223 minutes/week. Notes from the assessment stated the patient lives with her husband and has stairs to enter her home. 
The patient had a telephonic assessment tool later, assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing medication, and shopping while extensive assistance with tasks of transportation, bathing, and dressing lower body. The patient was assessed at limited assistance with task of managing finances while supervision with tasks stairs, walking, locomotion, and transfer toilet while set up only with phone use. With tasks of personal hygiene, dressing upper body, toilet use, bed mobility, and eating the patient was assessed as independent. Notes from an assessment stated the patient had decline in activities of daily living (ADLs) and deterioration of self-sufficiency since last assessment. The client task sheet calculated 228 minutes/week. At issue is the medical necessity of the requested increase in CDPAS service hours.

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

The patient's primary care provider noted the patient has an increased need of assistance in the home. The telephonic assessment tool showed an increase in assistance with tasks of meal preparation, managing medication and transportation. The client task sheet did not consider the patient's increased assistance needs with meal preparation and managing medication. The patient has unscheduled and unpredictable care needs over a continuum of time and the insurer failed to develop a plan to consider these unpredictable and unscheduled care needs (walking, locomotion, transfer toilet, and incontinence cares). The later assessment stated the patient had a decline in ADL status and deterioration in self-sufficiency. The increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs (instrumental activities of daily living). Considering the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 7 hours/day, 7days/week, to total 49 hours/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.