Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Personal Care home health care (HHC) - Level 2 Personal Care Services per 15 minutes increase to 84 hours per week.
The insurer denied: Personal Care home health care (HHC) - Level 2 Personal Care Services per 15 minutes increase to 84 hours per week
The denial is overturned.

The patient is a female with past medical history of Parkinson's disease, hyperlipidemia, gastroesophageal reflux disease (GERD), hypertension, congestive heart failure (CHF), chronic kidney disease, diabetes mellitus type 2, hearing loss, constipation, depression, anxiety, and urinary incontinence who had been assigned Personal Care Assistance (PCA) services 49 hours/week based on assessment performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and stairs while maximum assistance with tasks of shopping, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. With tasks of managing finances, managing medication, phone use, personal hygiene, dressing upper body, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. There was a request to increase PCA services and the patient underwent another assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, and shopping while maximum assistance with tasks of transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, transfer toilet, and toilet use. With tasks of managing finances, managing medication, phone use, bed mobility, and eating the patient was assessed at extensive assistance. Notes from the assessment stated the patient lived alone. The patient's medical provider sent a letter stating the patient was under the care of this provider and neurology and in the last month the patient's condition had significantly deteriorated with severe muscle spasms to the point that she could not get up out of the chair or from her bed. The letter also stated the patient was unable to reheat food and take care of herself which was affecting her daily living activities and the provider requested an increase in aide hours.
The subject under review is the medical necessity for Personal Care home health care (HHC) - Level 2 Personal Care Services per 15 minutes increase to 84 hours per week.

The health plan's determination is overturned.

The requested service of Personal Care home health care (HHC) - Level 2 Personal Care Services per 15 minutes increase to 84 hours per week is medically necessary. There is documentation from the patient's primary care physician (PCP) of worsening physical functioning in the month preceding the letter which was after the plan's assessment. The patient's PCP also documented medical necessity of increased PCA services. The assessment performed underestimated the patient's current assistance needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 when the patient does not have informal help. PCA services 84 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.