Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Home Health Care - 56 hours per week 
The insurer denied 56 hours per week, consumer direct, 1 client.
The denial is overturned.

The patient is a female with past medical history of coronary artery disease, hypertension, congestive heart failure (CHF), chronic atrial fibrillation on anticoagulation, status post aortic valve replacement, permanent pacemaker, dizziness/vertigo with history of falling, asthma, obesity, spinal stenosis, osteoarthritis, diabetes mellitus type 2, hypothyroidism, severe bilateral carpal tunnel syndrome, psoriasis, and urinary incontinence who had Consumer Directed Personal Assistance Program (CDPAP) services 42 hours/week. There was a request to increase CDPAP services and the patient underwent an assessment, assessing the patient at maximum assistance with tasks of ordinary housework and shopping while extensive assistance with tasks of meal preparation, stairs, transportation, bathing, dressing upper body, and toilet use. The patient was assessed at limited assistance with tasks of dressing upper body, walking, locomotion, and transfer toilet while set up only with tasks of managing finances, managing medication, and equipment management. With tasks of personal hygiene, bed mobility, and eating the patient was assessed as independent. 

The insurer sent final adverse determination denial notice denying request to increase CDPAP services, stating the request was not medically necessary and the patient did not meet criteria. The denial also stated safety supervision outside of specific daily activities was not a covered benefit. In addition, the insurer denial stated the patient could consider moving into a nursing home for long-term care or seeking services from the nursing home transition and diversion waiver program. The patient's primary care physician (PCP) provided a letter stating the patient remained stable for home living, however recent deterioration in medical condition and status required her to have a significant increase in home care hours. The PCP noted the patient needed more assistance throughout the day and night. The patient's PCP provided an M11Q form stating the patient's medical history and medications and stating the patient had progressive mobility problems with back, hands, and leg decreased range of motion and tremor and needed to increase home care service hours.

The health plan's determination is overturned.

The requested health service is medically necessary. There is documentation from the patient's PCP of functional decline and worsening medical conditions requiring an increase in assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). There was a request to increase CDPAP services from 42 hours/week to 56 hours/week. The insurer incorrectly stated that the patient had informal help. The patient requires at least limited assistance with transfer toilet, toilet use, walking, and locomotion. 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 increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 56 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.