Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory/Problems/Coronary Artery Disease/CAD
Treatment: Home Health Care; PCA services 12 hours/day, 7 days/week, to total 84 hours/week. 

The health plan denied the requested increase in personal care hours as not medically necessary. 

The health plan's determination is overturned.

The patient is a male with a past medical history of coronary artery disease, hypertension, diabetes mellitus type 2, end-stage renal disease on dialysis, congestive heart failure, and left below the knee amputation who had been assigned personal care assistant (PCA) services 10 hours/day, 7 days/week, to total 70 hours/week based on telephonic assessment tool performed, assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, shopping, transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet. With tasks of personal hygiene, dressing upper body, and toilet use, the patient was assessed at extensive assistance while set up only with tasks of managing finances, managing medication, and phone use. The patient was assessed at independent with tasks of bed mobility and eating. Notes from this assessment stated the patient was ambulating with a cane with noted assistance. The patient was hospitalized with a diagnosis of pulmonary embolism and there was a request to increase PCA services and the patient underwent an assessment tool, assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, shopping, and transportation while extensive assistance with tasks of stairs, equipment management, bathing, dressing lower body, walking, and locomotion. With tasks of managing finances, managing medication, dressing upper body, transfer toilet, and toilet use the patient was assessed at limited assistance while set up assistance with task of phone use. The patient was assessed at independent with tasks of bed mobility and eating. The patient was hospitalized with a myocardial infarction. The patient was hospitalized with pulmonary edema requiring an Intensive Care Unit (ICU) stay and intubation. The discharge summary stated the patient would benefit from an additional 2 hours of home care services per day to total 12 hours/day.
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.

Yes, There is documentation of functional decline when comparing the  assessments as noting the patient required the use of a cane and another person's assistance at the first assessment while requiring a walker and another person's assistance at the second assessment. Despite this noted worsening functional status there was noted improvement in tasks of bathing, personal hygiene, dressing upper body, dressing lower body, walking, locomotion, transfer toilet, and toilet use indicating the assessment underestimated the patient's care needs. In addition, the patient had hospitalizations 
x (times) 2 further causing a decline in functional status. The patient's medical provider from his second hospitalization requested an increase in home health hours. The patient requires at least limited assistance with transfer toilet, toilet use, walking, and locomotion. The patient has unpredictable and unscheduled care needs that span a continuum of time. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.