Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac Circulatory Problems/ Coronary Artery Disease (CAD).
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 male with a past medical history of ischemic cardiomyopathy, coronary artery disease, atrial fibrillation, chronic anticoagulation, oxygen requiring chronic obstructive pulmonary disease (COPD), hypothyroidism, gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH), urinary incontinence, permanent pacemaker, osteoarthritis, pulmonary hypertension, tremor, and recent placement of left ventricular mechanical assist (LVAD) device who had been assigned personal care assistant (PCA) services 6-1/2 hours/day, 7 days/week, to total 45.5 hours/week based on an assessment that assessed the patient at total assistance with ordinary housework while maximum assistance with tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet. The patient was assessed at extensive assistance with managing finances, equipment management, personal hygiene, dressing upper body, toilet use, and bed mobility while assessed at set up only with phone use and independent with eating. At issue is the medical necessity of the requested increase in personal care assistant hours.

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

The patient has progressive chronic medical conditions of osteoarthritis, ischemic cardiomyopathy with LVAD, and pulmonary hypertension. There is documentation of the patient's worsening functional status following the LVAD procedure. The patient does not have reliable informal or formal support. The patient requires at least extensive assistance with all activities of daily living (ADLs) / instrumental activities of daily living (IADLs) . The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to address these unpredictable and unscheduled care needs. The patient's care needs cannot be met with current PCA hours and/or adaptive equipment and/or medical supplies. The increase in PCA services hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. With placement of an LVAD, the patient now must carry a case with the LVAD and manage with oxygen via nasal cannula. The patient does not have vision in left eye, making it difficult for the patient to take medication, feed himself and ambulate. The patient's tremor makes it difficult for him to feed himself as well. 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 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.