Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/ Kidney Disorder - Incontinence/Urinary/Bladder Control

Treatment: Home Health Care- health service/treatment of Personal Care Worker (PCW) Services-7 days per week, 24 hours per day, live in; 91 hours per week. 

The health plan denied the requested health service/treatment of Personal Care Worker (PCW) Services-7 days per week, 24 hours per day, live in; 91 hours per week as not medically necessary. 

The health plan's determination is overturned.

The patient is a female with a medical history notable for severe essential tremor, coronary artery disease, congestive heart failure, atrial fibrillation, degenerative joint disease, and history of falls. The patient is approved for 12 hours per day, 7 days per week (84 hours per week) of Personal Care Worker (PCW) services. The patient and her care team requested an increase to 7 days per week, 24 hours per day live-in (91 hours per week). 
A letter of support for this appeal was provided by the patient's internal medicine physician stating that the patient was hospitalized for 10 days and discharged to a skilled nursing facility. Since her discharge back home from the skilled facility, she was found to have a "significant decrease in all aspects of her functional abilities." In addition to worsening transfers and mobility issues, she is now totally incontinent of bowel and bladder. She has a history of pressure ulcers, and the physician recommends periodic turning and repositioning to prevent recurrence.
A letter by the patient's family medicine physician states that she has "abruptly deteriorated over the past few months" since her discharge from the hospital and skilled nursing facility. This physician also feels that an increase in home health hours is medically necessary.
A letter by the patient's son also describes the decline in functional status following the patient's hospitalization and details her requirement for human assistance with activities of daily living.
Notes from her admission to the skilled nursing facility were provided and state that the patient is extensive assist for most activities. She is 1 or 2 person assist.
A Uniform Assessment System (UAS) was completed. The patient was found to have modified independence with cognition; short term and procedural memory was intact. For her functional status, she requires total dependence for meal preparation and housework. She requires maximal assistance for managing medications, stairs, shopping, and transportation. For her activities of daily living (ADL), she requires maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and bed mobility. She was noted to be frequently incontinent of urine (with some control present) and continent of stool. Her functional status showed a slight decline from the prior assessment.
At issue is the medical necessity of the requested health service/treatment of Personal Care Worker (PCW) Services - 7 days per week, 24 hours per day, live in; 91 hours per week.

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

Two physicians and the patient's son have attested to a dramatic decline in functional status following the patient's hospitalization. This decline does not appear to be fully captured in the most recent UAS. The patient now requires hands on assistance for all ADL's and has incontinence of both bowel and bladder. It is common for functionally limited geriatric patients to reset to a lower baseline of functioning following recovery from an acute hospitalization. She will need assistance with diaper changes and toileting throughout the day and night. These personal care tasks cannot be scheduled into a 12-hour window, and thus, around the clock (24-hour) care must be provided. Her personal care needs will be periodic and unpredictable. The personal care aide can be expected to get a reasonable night's sleep, and thus, live-in care is appropriate.