Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension
Treatment: Home health Care
The health plan denied the requested increase in PCA hours. 
The health plan's determination is overturned.

The patient is a female with a past medical history of hypertension, hyperlipidemia, diabetes mellitus type 2, severe osteoarthritis (OA), gastroesophageal reflux disease (GERD), cognitive decline, anxiety, and bladder incontinence who had been assigned personal care assistance (PCA) services 4 hours/day, 7days/week, to total 28 hours/week. The patient had been attending social daycare up until the start of the COVID-19 pandemic. There was a request to increase PCA services and the patient underwent an assessment tool assessing the patient at total assistance with task of ordinary housework while maximal assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of managing finances, transportation, equipment management, bathing, dressing upper/lower body, and transfer toilet while limited assistance with tasks of managing medication, phone use, walking, locomotion, toilet use and eating. With the task of bed mobility the patient was assessed as independent. The notes from this assessment stated the patient lives alone and has had increasing difficulty with knee/leg pain since not attending social daycare, as well as a 10 pound weight loss. The patient uses a walker indoors and a wheelchair outdoors. The daughter provided a letter stating the patient had a 3 falls, is not able to do chores or cooking in the morning, and the aide comes at 2 pm so patient is unable to eat until then. When she fell she had to be hospitalized overnight. The patient's provider in the hospital provided a letter stating due to worsening of her pain from her arthritis and debility the patient requires increasing need of assistance to carry out her activities of daily living. The letter further recommended increase in home attendant hours to at least 8-12 hours per day. 
At issue is the medical necessity of the requested increase in PCA hours.

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

Yes. The patient had a documented decline in functional status following the initiation of the COVID-19 pandemic when she no longer attended social day care. The patient's daughter documented the patient is unable to attend to morning and lunchtime routine as the aide is not present until 2 pm which has resulted in the patient not eating until the aide arrives with documented weight loss. The patient needs assistance with all activities of daily living (ADLs) / instrumental activities of daily living (IADLs) except bed mobility. Some of these needs could be scheduled but many are unpredictable and unscheduled. Specifically tasks of walking, locomotion, transfer toilet and toilet use are unpredictable and unscheduled care needs that would occur outside of the time the patient has an informal helper or PCA. Increase in PCA hours is not solely for safety and supervision but to assist the patient with the safe completion of ADLs and IADLs. The patient's primary care provider and the attending physician who took care of her during her hospital stay document the medical necessity of increased PCA hours. 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.