Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Congestive Heart Failure
Treatment: Personal care aide services: 12 hours per day - 7 days per week - total of 84 hours per week.
The insurer denied the Personal care aide services: 12 hours per day - 7 days per week - total of 84 hours per week.
The determination is overturned.

The patient has a past medical history of blindness, congestive heart failure, diabetes mellitus (DM) type 2, neuropathy, obesity, osteoarthritis, cerebrovascular accident (CVA), coronary artery disease (CAD), permanent pacemaker, anxiety, occasional incontinence and weakness/fatigue related to cardiac issues who had been assigned personal care aide (PCA) services at 11 hours/day, 7 days/week to total 77 hours/week based on assessment tool performed. The patient was hospitalized with shortness of breath and was diagnosed with a pulmonary embolism (PE). The patient was placed on hospice due to chronic congestive heart failure. There was a request to increase PCA hours to 12 hours/day, 7 days/week to total 84 hours/day. The patient had an assessment tool performed and another with improvement in tasks of meal preparation and transportation from total assistance to maximum assistance. The patient had no change in all other tasks assessed at total assistance for tasks of ordinary housework, managing finances, shopping and locomotion, maximum assistance for tasks of managing medication, phone use, stairs, bathing, personal hygiene, dressing upper/lower body, walking, transfer toilet and toilet use and extensive assistance with bed mobility and eating.
The final adverse determination letter noted keeping the PCA services at 77 hour/week. A letter from the primary care physician (or provider) (PCP) noted that the patient requires the presence of another adult to assist with ambulation and to get in/out of the bathroom. The daughter provided a letter stating the patient cannot walk with a walker as noted in the final adverse determination letter but that he had a decline in his health and was not able to walk even with assistance. In addition, she noted the patient was not able to activate Personal Emergency Response Systems (PERS) systems as stated in final adverse determination letter as he is blind and has declining mental health with periods of confusion due to escalation of pain medication. A hospice physician increased the patient's fentanyl and noted the patient had significant pain symptoms. At issue is the medical necessity of an increase in personal care aide services: 12 hours per day - 7 days per week - total of 84 hours per week.
The requested services are medically necessary. The patient is noted by his PCP and hospice physician to have worsening of chronic medical conditions with the need for increased help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient has had a significant change in his medical conditions since his previous assessment tool was performed. The assessment tool underestimated the patient's assistance needs for most ADL tasks, as due to blindness, worsening CHF and chronic severe pain limiting his ability to walk, move and transfer. In addition, the medication that is prescribed to control pain has worsened the patient's mental status causing some confusion necessitating increased help with meal preparation, managing medication, stairs, bathing, personal hygiene, dressing upper/lower body, transfer toilet, toilet use and bed mobility. The increase in PCA service hours is not soley for supervision and safety but for assisting the patient in completion of ADL and IADL tasks.