Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardic/Circulatory Problems. 
Treatment: Home Health Care. 
The insurer denied increase in personal care services to 10 hours a day 7 days a week. 
The denial is overturned.

The patient is a female with past medical history of congestive heart failure, hypertension, hyperlipidemia, osteoarthritis, osteoporosis, hearing loss, chronic pain, urinary incontinence, and cognitive decline who had been assigned Personal Care Assistance (PCA) services hours 7 hours/day, 6 days/week, and 5 hours/day, 1 day/week, to total 47 hours/week. There was a request to increase PCA hours to 10 hours/day, 7 days/week, to total 70 hours/week. The patient had a telephonic assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, and transportation while maximal assistance with tasks of managing medication, phone use, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes from the assessment stated the patient was forgetful, was not able to recognize family members, was currently attending physical therapy (PT), was using a walker in the home, was unable to feed herself, and had severe fatigue. The health plan sent final adverse determination denial notice stating the service was not medically necessary and the patient did not meet criteria. The denial notice further stated the plan provides incontinence supplies and the patient has a walker and wheelchair to help the patient move about her environment. In addition, the denial stated the plan does not provide PCA hours for companionship, safety supervision, and safe transfers. The plan approved PCA services 7 hours/day, 7 days/week to total 49 hours/week. The patient's daughter provided a letter stating the patient's functional limitations which have been worsening and the patient's daughter is not able to provide informal care as the assessment tool stated. The patient's daughter has her own medical issues, lives 1.5 hours away, and has to care for her spouse. The daughter's letter also noted the patient's granddaughter is not able to provide informal care as she works full time and lives two hours away. The patient/patient's family appealed the denial decision. The subject under review is the medical necessity for the increase in personal care services to 10 hours a day, 7 days a week.

The health plan's determination is overturned.

Yes, the requested increase in personal care services to 10 hours a day 7 days a week is medically necessary for this patient.
The patient is a female with multiple progressive medical diagnoses and documented need with assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADL). The patient does not have informal help from her daughter and granddaughter per letter from the patient's daughter. An increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. PCA 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.