Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Home Health Care
The insurer denied Personal Care Services (PCS) 12 hours a day, 5 days a week, for a total of 60 hours per week. 
The denial is overturned in whole.

The patient is a female with a past medical history of ischemic colitis, fecal incontinence, urinary incontinence, hypothyroidism, rheumatoid arthritis, congestive heart failure, hip fracture, shoulder fracture, ischemic cardiomyopathy, coronary artery disease, hypertension, hyperlipidemia, spinal stenosis, and chronic kidney disease who had been assigned personal care assistance (PCA) services 6 hours/day, 5 days/week to total 30 hours/week. There was a request to increase PCA services and the patient underwent video assessment, assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, shopping, transportation, bathing, personal hygiene, dressing upper/lower body, transfer to the toilet, and toilet use while extensive assistance with tasks of managing finances, managing medication, and bed mobility. The patient was assessed at set up with task of phone use and independent with task of eating. Notes from the assessment stated the patient lived alone, had a decline in activities of daily living (ADLs) status over the last 90 days, and had a deterioration of overall self-sufficiency over the last 90 days.

The patient had a fall with subsequent left humeral fracture then hospitalization for ischemic colitis. The patient's social worker provided a letter stating the patient would benefit from increased home health aide hours to meet daily living needs. The social worker noted, as per physical therapy (PT) notes, the patient was still unsteady during sit to stand transfers, ambulation, and stair negotiation and would need to be supervised at all times during these tasks. Lastly, the provider requested an increase in home care hours. The patient's primary care physician (PCP) provided a letter stating the patient had inadequate PCA hours. The patient's social worker provided a letter stating the patient had a fall with humeral fracture 2-3 months prior. The patient's health care advocate provided a letter requesting an external appeal of denial decision.

At issue is the medical necessity of Personal Care Services (PCS) 12 hours a day, 5 days a week, for a total of 60 hours per week.

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

The requested health service/treatment of PCS 12 hours a day, 5 days a week, for a total of 60 hours per week is medically necessary for this patient.

The patient has a documented functional decline following multiple falls over a period of the last two years. The patient requires at least maximum assistance with tasks of locomotion, walking, transfer to the toilet, and toilet use. 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. The patient's increased care needs are not solely for safety and supervision, but to assist the patient with safe completion of ADLs/instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 12 hours/day, 5 days/week, to total 60 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.

Therefore, the requested health service/treatment of PCS 12 hours a day, 5 days a week, for a total of 60 hours per week is medically necessary.