Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myocardial Infarction
Treatment: increase in personal care services from 40 hours to 84 hours per week.
The insurer denied an increase in personal care services from 40 hours to 84 hours per week.
The determination is overturned.

The patient has a past medical history of hypertension, coronary artery disease, diabetes mellitus type 2, osteoarthritis, hypothyroidism, gastroesophageal reflux disease (GERD), urinary incontinence, depression, anxiety, and mild cognitive impairment who had been assigned personal care assistant (PCA) services 4 hours/day, 7 days/week, to total 28 hours/week based on an assessment performed assessing the patient at total assistance with task of ordinary housework while maximum assistance with the tasks of meal preparation, managing finances, and shopping. With the tasks of managing medication, stairs, transportation, bathing, dressing upper/lower body, the patient was assessed at extensive assistance while limited assistance with task of personal hygiene. The patient was assessed at set up help only with the task of phone use and independent with the tasks of walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The patient was hospitalized with an ST-Elevation Myocardial Infarction (STEMI) initially with plans to be discharged to short-term rehabilitation (rehab). The case management notes stated the patient would need increased home health aide (HHA) hours upon discharge to home from the Skilled Nursing Facility (SNF). In addition, the patient's discharge summary noted the patient was going to a Skilled Nursing Facility (SNF) and upon discharge from there would need an increase in HHA. The patient decided he wanted to return home and not go to the SNF. There was a request to increase personal care assistant (PCA) services and the patient underwent another assessment assessing the patient at total assistance with the tasks of meal preparation and ordinary housework while maximum assistance with tasks of managing finances, stairs, shopping, bathing, and dressing lower body. With the tasks of managing medication, transportation, and dressing upper body the patient was assessed at extensive assistance while limited assistance with tasks of phone use, personal hygiene, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at independent with the tasks of bed mobility and eating.
Notes from the assessment stated the patient's wife and daughter had died last year and the patient was lonely and needed more help. The insurer sent an initial adverse determination denial notice partially denying increase in PCA services approving 40 hours per week. The denial also stated plan assessments were not required to include safety monitoring as a separate task for dementia, fall prevention, and pain management. On the same day the insurer sent a final adverse determination denial notice denying the request to increase PCA services stating that the patient had been reassessed and based on this assessment authorized hours for PCA services were adjusted accordingly. The patient's primary care physician (or provider) provided a letter requesting an increase in hours for a home health aide. The letter noted the patient needed continuous supervision and help in all of his activities of daily living, personal care, and to maintain home safety. The provider stated it was in their professional opinion that the patient must have a home health aide 24 hours/day, 7 days a week to maintain his current health status, prevent his illness from progressing, provide prevention of falls and further hospital admissions.
The patient's medical provider who had been doing home visits monthly sent a letter stating the patient lived alone and the provider was requesting an increase in home care hours due to rapidly deteriorating mental state and physical health based on their clinical findings. The letter also stated the patient was exhibiting signs of dementia onset and the patient had recently suffered an extensive myocardial infarction with a decline in his health following this event. In addition, the provider stated the patient's memory and mental state had suffered and rapidly declined following the coronary event and patient was unable to warm a meal for himself, do any grocery shopping, or any housekeeping tasks. The provider also noted the patient was able to ambulate with a walker very slowly, however, needed verbal guidance to remember to use the walker and became short of breath with minimal exertion and needed to rest to catch his breath. The provider also stated the patient was no longer able to prepare or remember to take his medications, several of which need to be administered before meals and several in the evening. In addition, the provider stated the patient needed to check his blood sugar regularly which was a task he was no longer able to perform and the patient required blood pressure check twice a day but the patient was unable to use the blood pressure monitor device on his own. Lastly, the provider recommended home health aide hours 24 hours/day. The patient appealed the denial decision. The patient's physician provided an attestation for an external appeal. The patient's healthcare advocate provided a letter requesting an external appeal on behalf of the patient. At issue is the medical necessity of an increase in personal care services from 40 hours to 84 hours per week.

Yes, the services are medically necessary. There is documentation of worsening mental and physical functioning following hospitalization for a myocardial infarction. The patient's daughter and wife had died last year and the patient no longer had informal assistance. The patient's medical providers have documented medical necessity of PCA services 24 hours/day, 7 days/week. The assessment showed an increase in assistance needs with tasks of meal preparation, phone use, stairs, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient requires assistance with medication management outside of the hours presently assigned to the patient. 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). Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, 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 his own home.