Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Coronary Artery Disease/CAD
Treatment/Home Health Care: Consumer directed personal care assistance services (8 hours per day, 7 days per week, a total of 56 hours per week).
The health plan denied the requested Consumer directed personal care assistance services (8 hours per day, 7 days per week, a total of 56 hours per week) as not medically necessary. The health plan's determination is overturned.

This is a case review for a male with medical history notable for heart failure, coronary artery disease, diabetes, hypertension, and weakness. The patient is approved for 33 hours per week of consumer directed personal care assistance services. The patient and his care team requested an increase to 8 hours per day, 7 days per week (56 hours per week) and this request was denied by the health plan. This denial is the subject under review.
The patient's physician provided a letter of medical necessity for this appeal. The letter states that the patient's medical conditions are impacting his ability to perform personal care tasks. He requires assistance with bathing, dressing, and toileting. The physician requests an increase in personal care hours to meet his needs.
Physician office visit notes were provided for review. The notes discuss his challenges with unmet personal care needs. Without assistance, the patient is unable to complete any activities of daily living (ADL). The patient can safely ambulate with a rollator with a seat. He has been developing urinary incontinence which has worsened since the last evaluation. The physician recommended 8 hours per day of personal care assistance.
A letter was provided from an unnamed team member. The letter states that the patient struggles with ambulation and had a fall last year while walking on flat ground. There are several photos attached which show extensive facial bruising after the fall.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person. The patient lives alone in an apartment which is not handicap accessible and requires six steps at the front entrance. The patient was alert and oriented. His mini-mental state examination score was 22/30 indicating possible mild cognitive impairment. For his instrumental activities of daily living (IADL), he requires maximal assistance for housework and meal preparation. He requires extensive assistance for stairs, shopping, and medications. For his ADL, he requires extensive assistance for bathing, dressing lower body, and toilet transfer. He requires limited assistance for dressing upper body. He is independent in other domains. He was infrequently incontinent of urine and continent of stool. A task tool associated with the assessment recommended 32.8 hours per week to address his personal care needs.
At issue is the medical necessity for the requested health service/treatment of consumer directed personal care assistance services (8 hours per day, 7 days per week, a total of 56 hours per week).

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

The requested health service of consumer directed personal care assistance services (8 hours per day, 7 days per week, a total of 56 hours per week) is medically necessary for this patient.
The patient has had a progressive functional decline due to his advanced age and multiple medical conditions. The UAS is now nearly six months old, and more recent physician notes reflect a worsening of his functional status. The patient requires assistance with toileting and has had worsening incontinence. He suffered a fall when attempting to ambulate on flat ground last year, which is evidence that he cannot ambulate without assistance. The requested increase in personal care hours is medically necessary and appropriate for the patient.