Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Parkinson's Disease. 
Treatment: Home Health Care. 

The health plan denied the requested increase in personal care assistance hours as not medically necessary. 

The health plan's determination is overturned. 

The patient is a female with a past medical history of congestive heart failure (CHF), hyperlipidemia, right eye blindness, kidney cancer, diabetes mellitus (DM) Type 2, dementia, pressure ulcer buttocks, urinary incontinence, bowel incontinence, Parkinson's disease, hearing loss, sciatica, history of multiple falls, dementia, dysphagia, and osteoporosis who had a telephonic assessment while in rehabilitation. The patient was discharged from rehabilitation following a 15 month stay. There was a request for consumer directed personal assistance service/personal care assistance (CDPAS /PCA) Level 2 services 12 x 12 hours/day, split-shift, 7 days/week, to total 168 hours/week. The insurer sent initial adverse determination denial notice stating they tried to contact the patient/family unsuccessfully. The patient underwent a telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, meal preparation, phone use (activity did not occur), stairs (activity did not occur), shopping, transportation (activity did not occur), bathing, dressing lower body, locomotion, and toilet use while maximum assistance with tasks of personal hygiene and dressing upper body. The patient was assessed at extensive assistance with tasks of bed mobility and eating and the activities of walking and transfer toilet were noted as "activity did not occur" with no estimated assessment of assistance needs. Notes from assessment stated the patient was unable to express goals, lived with spouse, was unable to perform the Mini-Mental State Examination (MMSE), was bed bound, activities of daily living (ADL) status declined, required puree diet, and had no pressure ulcers. 

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

The patient has documented progressive medical conditions of dementia, osteoporosis, and Parkinson's disease. The patient has had documented decline in mental and functional status. The patient has urinary and bowel incontinence and pressure ulcers of the buttocks. The patient has unpredictable and unscheduled care needs and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient requires at least extensive assistance with all activities of daily living (ADLs) / instrumental activities of daily living (IADLs) based on an assessment tool. The approved CDPAS/PCA hours of 84 hours/week and/or adaptive equipment and/or medical supplies are not sufficient to meet the patient's ADL/IADL care needs. The requested increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient has buttock ulceration/skin breakdown with the need to be repositioned every 2 hours. The patient's ADL care needs would not allow CDPAS/PCA to obtain at least 5 hours of uninterrupted sleep. 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, CDPAS/PCA services 12 x 12 hours/day, split-shift, 7 days/week, to total 168 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.