Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bowel incontinence
Treatment: Home care/personal care HHC (home health care) level 2 personal care services per 15 minutes increase to 168 hours per week.
The insurer denied home care/personal care HHC level 2 personal care services per 15 minutes increase to 168 hours per week.
The determination is upheld.

The patient has a past medical history of hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), anxiety, depression, diabetes mellitus (DM) type 2, urinary incontinence, bowel incontinence, hemiplegia, osteoporosis, and osteoarthritis who had been assigned Consumer Directed Personal Care Services (CDPAP) services 70 hours/week. The assessment estimated 44.75 hours via tasking tool and the patient was assessed at total assistance with all tasks except for meal preparation, managing medication, dressing upper body, and transfer toilet for which she was assessed at maximum assistance while extensive assistance with tasks of bed mobility, and eating.

There was a request to increase CDPAP services and the patient underwent another assessment assessing the patient at total assistance with all tasks. Notes from that assessment noted the patient had severely impaired cognitive function, activities of daily living (ADL) status had declined over the last 90 days, and overall self-sufficiency had deteriorated over the last 90 days. The assessment also noted the patient was bedbound and required 2 people to assist with transfer. The patient's Nursing Facility Level of Care (NFLOC) score was 43.
The insurer sent an initial adverse determination denial notice denying the to increase CDPAP services stating the recent assessment did not show a change in social circumstances and the patient lived with and had the support of her family. The denial also stated the patient's current assessment showed the personal care services that the patient was receiving were sufficient to meet the patient's needs. The plan also recommended that the patient split the services to better meet her care needs and safety monitoring is a part of the total service hours allotted. The insurer sent a final adverse determination denial notice continuing to deny request to increase CDPAP services stating services would remain at 72 hours per week. The denial references a letter of medical necessity (which was not included in the review materials) which stated the patient needed care 24/7 for her activities of daily living (ADLs). The denial also stated the patient had no nighttime needs that cannot be treated either nonpharmacologically or pharmacologically and the patient was receiving 72 hours of care per week which was 3 percent (%) more care hours than her tasking tool estimated. The patient and her family appealed the denial decision as well as her medical provider. At issue is the medical necessity of home care/personal care HHC level 2 personal care services per 15 minutes increase to 168 hours per week.

The services are not medically necessary. Although the patient has care needs with all ADLs and Instrumental activities of daily living (IADLs), there is no documentation of medical necessity of 24-hour care, split shift. There is no documentation of assistance needs in the overnight hours that would not allow a CDPAP at least 5 hours of uninterrupted sleep. There is no documentation of the need for the patient to be turned and repositioned every 2 hours. 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, CDPAP services 168 hours/week are not medically necessary for this patient.