Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure.
Treatment: Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week.
The insurer denied Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week.
The determination is overturned.

This is a female patient with a past medical history of coronary artery disease (CAD), congestive heart failure (CHF), hypertension, diabetes mellitus type 2, osteoporosis, osteoarthritis, bowel incontinence, urinary incontinence, gastroesophageal reflux disease (GERD), breast cancer, lung cancer, and chronic obstructive pulmonary disease (COPD) who had been assigned personal care assistant (PCA) services 52 hours/week Tasking tool estimated 47.83 hours. The patient was hospitalized with congestive heart failure (CHF). There was a request to increase PCA services and the patient underwent another assessment assessing the patient at total assistance with the tasks of ordinary housework and stairs while maximum assistance with the tasks of meal preparation, shopping, transportation, bathing, dressing lower body, walking, and locomotion. With the tasks of managing finances, managing medication, personal hygiene, dressing the upper body, transferring toilet, and toilet use the patient was assessed with extensive assistance with limited assistance with the tasks of phone use, bed mobility, and eating. Notes from the assessment noted the patient had a decline in activities of daily living (ADLs) status over the last 90 days as well as a deterioration of overall self-sufficiency. In addition, notes stated the patient had right arm weakness causing difficulty with ADLs. The tasking tool is estimated at 42.42 hours/week.
The patient's primary care physician (or provider) (PCP) provided a letter requesting an urgent increase in hours of home care due to the patient's rapidly deteriorating mental state, physical health, and functional status based on the provider's clinical findings. Lastly, the letter stated the provider recommended and believed it was very important and medically necessary for the patient to have 12 hours of home care daily, 7 days/week. At issue is the medical necessity of Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week. 
The services are medically necessary.
There is documentation from the patient's medical provider of the medical necessity of increased PCA services. The video assessment underestimated the patient's assistance needs with dressing upper/lower body, locomotion, transfer toilet, and toilet use as the patient had documented a decline in functional status, but the assessment noted improvement in these areas when compared to the prior assessment. There is documentation that the patient requires at least extensive assistance with transfer toilet, toilet use, walking, and locomotion, and therefore, 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 plan assumed the patient had informal help outside of the currently assigned PCA services which is not the case. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with the safe completion of ADLs and Instrumental activities of daily living (IADLs). The requested increase in PCA services cannot be met solely with adaptive equipment and medical supplies.