Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Home Health Care (increase in personal care assistance hours, level 2, to 84 per week). 
The insurer denied the Home Health Care (increase in personal care assistance hours, level 2, to 84 per week).  The denial is overturned.

The patient is a female with past medical history of hypertension, diabetes mellitus (DM) type 2, Alzheimer's dementia, osteoporosis, syndrome of inappropriate antidiuretic hormone (SIADH), orthostasis, hyperlipidemia, urinary incontinence, insomnia, and anxiety. The patient had a fall with head injury with subsequent hospitalization and then again with subsequent hospitalization. The patient was hospitalized with urinary tract infection (UTI) and subsequently underwent assessment tool over the telephone for Personal Care Assistance (PCA) services. The patient was assessed at total assistance with task of ordinary housework and maximum assistance with tasks of meal preparation, managing finances, shopping, and transportation. With the tasks of managing medication, phone use, stairs, bathing, and dressing upper/lower body, and toilet use the patient was assessed at extensive assistance, while limited assistance with task of personal hygiene. The patient was assessed at supervision only with tasks of walking, locomotion, transfer toilet, bed mobility, and eating. Following this assessment, the patient was assigned Consumer Directed Personal Assistance Program (CDPAP) services 6 hours/day, 5 days/week, to total 30 hours/week.

The plan sent final adverse determination denial notice continuing to deny request to increase PCA services. The healthcare advocate provided a letter requesting an internal appeal due to denial of request to increase PCA services. The letter noted the patient was prescribed medication that increased likelihood of joint pain, dizziness, and blurred vision and reiterated statements from the earlier letter. The plan sent a letter stating the main reason additional hours would be required was to provide safety and supervision alone and the request for extra hours was not medically necessary. The patient's health care advocate provided a letter stating the requested services are medically necessary with reiteration of the content of previous letters provided. The subject under review is the medical necessity for the increase in personal care services to 84 hours per week.

The health plan's determination is overturned.

The patient has documented chronic medical illnesses with decline in functional and mental capabilities. The patient requires at least some assistance with all of her activities of daily living (ADLs)/instrumental activities of daily living (IADLs). The patient's telephonic assessment underestimated some of the patient's care needs, based on the attending physician's statement and information provided by the patient's health care advocate. The patient no longer has informal support from her daughter and this should be taken into consideration when determining PCA service hours. The patient has unscheduled and unpredictable care needs over a continuum of time. The plan stated in the final adverse determination denial notice that the patient was able to stand up, walk, and use the bathroom independently. The patient's attending physician noted the patient's need for assistance with walking, locomotion, and toilet use. The requested increase in PCA hours is not solely for safety and supervision but to assist the patient with ADLs/IADLs. Taking into account all the information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient.