Appeal type: Medical necessity
Decision: Overturned

Diagnosis: 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 chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), osteoarthritis, coronary artery disease, hypertension, gastroesophageal reflux disease (GERD), chronic bronchitis, macular degeneration, and chronic respiratory failure who had been assigned personal care assistant (PCA) services 6 hours/day, 7 days/week to total 42 hours/week based on an assessment following hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation. At this assessment, the patient was assessed at maximum assistance with the tasks of meal preparation, ordinary housework, shopping, and transportation while extensive assistance with tasks of managing medication, stairs, bathing, and dressing lower body. With the tasks of managing finances, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance while set up only for phone use and independent with tasks of bed mobility and eating.
Notes from the assessment noted the patient was continent of urine. The patient was hospitalized again with COPD, pneumonia, and required computed tomography (CT)-guided pleural drainage. There was a request to increase PCA services and the patient underwent another assessment  assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance with the tasks of managing finances, stairs, and transportation. The patient was assessed at extensive assistance with tasks of managing medication, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use while limited assistance with task of bed mobility. With the task of phone use the patient was assessed at set up only assistance while independent with task of eating. Notes from the assessment noted the patient was status post hospitalization, lived alone, activities of daily living (ADL) status had declined, overall self-sufficiency deteriorated, and the member was not able to manage incontinence by himself with the use of a diaper. 
The insurer sent an initial adverse determination denial notice denying the request to increase PCA services stating there had been a reported change in the patient's clinical condition related to his recent hospitalization but the discharge paperwork indicated that the condition was stable at the time of discharge. The denial also stated the assessment supported 32 hours of personal care services per week using a task based system and the patient was receiving 42 hours/week. Lastly, the denial stated plan assessments were not required to include safety monitoring as a separate task for supervision and falls.
The insurer sent a final adverse determination denial notice denying request to increase PCA services stating the recent assessment showed many of his abilities to perform daily activities stayed the same compared to an assessment completed. The denial also stated additional hours were not provided for stand-alone safety supervision, companionship or when the aide was not performing tasks. The patient's primary care physician (PCP) provided a letter requesting urgent increase in hours of home care due to the patient's rapidly deteriorating mental and physical health and functional status. The letter further stated the patient had great difficulty with ambulating and was dependent on a walker and was only able to walk approximately 15 steps without stopping for rest. The letter also noted the patient had been hospitalized the week before for repeat pleural drainage due to recurrent fluid buildup in the pleural space making it extraordinarily difficult for the patient to breathe and function normally. In addition, the patient's PCP noted the patient was highly prone to falls and due to urinary incontinence the patient wore diapers and required multiple daily changes of soiled diapers and linens to preserve skin integrity. Lastly, the PCP recommended and believed it was very important and medically necessary for the patient to have 12 hours of home care daily, 7 days/week. A community friend sent a letter noting that the nurse at his assessment did not ask him to ambulate by himself or get out of bed and the patient was not able to go to bed on his own, could not change his diaper, and has dizziness and severe hypotension.
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 from the assessments that the patient required increased assistance with multiple ADLs and instrumental activities of daily living (IADLs) including meal preparation, ordinary housework, managing finances, stairs, shopping, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility when comparing the assessments. The patient's PCP requested an increase in PCA hours as medically necessary. The patient has a documented decline in functional status with multiple hospitalizations over the last 6 months. The patient lives alone. The insurer's assessment noted the patient was not able to manage urinary incontinence on his own. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable 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 and Instrumental activities of daily living (IADLs) . The patient's care needs cannot be met solely with medical supplies and adaptive equipment. 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 his own home.