Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Age related cognitive decline
Treatment:  Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 70 hours per week
The insurer denied Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 70 hours per week.
The determination is overturned.

The patient has a past medical history of hypertension, hypothyroidism, hyperlipidemia, congestive heart failure, gastroesophageal reflux disease (GERD), osteoarthritis, anxiety, depression, history of breast cancer, coronary artery disease, and urinary incontinence who had been assigned personal care assistant (PCA) services 56 hours/week based on assessment tool performed telephonically assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances, stairs, and transportation. With the tasks of managing medication, phone use, bathing, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with task of personal hygiene. The patient was assessed at independent with tasks of bed mobility and eating. The tasking tool estimated 29.92 hours/week.
There was a request to increase PCA services and the patient underwent an assessment via video assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, and locomotion while maximum assistance with tasks of phone use, bathing, dressing lower body, transfer toilet, and toilet use. With the tasks of personal hygiene and dressing upper body the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating. Notes from the assessment stated the patient used a walker indoors and a wheelchair outdoors, the patient had moderate deformity of both hands and was unable to hold anything, and the patient was treated with diuretic therapy which caused increased urinary frequency. The tasking tool estimated 52.92  hours/week. The insurer sent an initial adverse determination denial notice denying the request to increase PCA services. The insurer sent a final adverse determination denial notice denying request to increase PCA services stating there was no letter of medical necessity, the patient's activity of daily living status declined and overall self-sufficiency had deteriorated from prior assessment, the patient had not fallen or had an evaluation in the emergency department in the past 90 days, the patient's medical diagnoses and medications were only minimally changed, and assigned care hours were 6% more than what tasking tool estimated.
At issue is the medical necessity of home care/personal care [HHC]- level 2 personal care services, per 15 minutes increase to 70 hours per week. 
The services are medically necessary. There is documentation by the plan's assessment of worsening functional status from previous assessment. In addition, the patient had a video assessment which may have underestimated the patient's care needs. The patient had been provided 56 hours/week of PCA services prior to the assessment when her tasking tool had estimated 29.92 hours of assistance. The hours of assistance have essentially doubled on the task-based worksheet. The insurer's tasking tool noted the patient had a decline in activities of daily living (ADL) status and deterioration in overall self-sufficiency, furthermore, the patient has 24-hour care needs as she does require maximum assistance with transfer toilet and toilet use as well as total assistance with locomotion and maximum assistance with walking; therefore, a task-based tool should not have been used to calculate the patient's hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Even though there is not documentation from the patient's medical provider of the medical necessity of increased PCA services, the nursing assessment was sufficient to determine the patient needs an increase in hours. 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 70 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.