Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall Risk. 
Treatment: Home Health Care (HHC)/personal care - level 2 personal care services, per 15 minutes increase to 84 hours per week. 

The insurer denied home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week. 

The determination is overturned. 

This is a female patient with a past medical history of osteoporosis, subdural hematoma, gastroesophageal reflux disease (GERD), dementia, urinary incontinence, hearing loss, anxiety, hypertension, legal blindness, lung cancer, osteoarthritis, atrial fibrillation on chronic anticoagulation, and macular degeneration who had been hospitalized with a blood clot. The patient underwent an assessment via video assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance of managing finances, managing medication, phone use, stairs, transportation, bathing, dressing lower body, and transfer toilet. The patient was assessed at extensive assistance with the tasks of equipment management, personal hygiene, dressing upper body, walking, locomotion, and toilet use while limited assistance with task of bed mobility. The patient was assessed at supervision with the task of eating. The tasking tool estimated 47.08 hours/week. 

The patient was admitted to the hospital due to pneumonia and chronic obstructive pulmonary disease (COPD). There was a request to increase personal care assistant (PCA) services and the patient underwent another video assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance with the tasks of managing medication, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With the task of bed mobility the patient was assessed at extensive assistance. Notes from the assessment stated the patient used oxygen and a rollator walker. The tasking tool estimated 28.5 hours/week. 

The insurer sent an initial adverse determination denial notice denying request to increase PCA services stating the patient did not meet criteria and plans' assessments are not required to include safety monitoring as a separate task for falls. The insurer sent a final adverse determination denial notice continuing to deny the request to increase PCA services stating there had been no recent falls or change in family or social circumstances and current personal care hours were sufficient to meet the patient's functional care needs. The patient's medical provider sent a letter in full support of the request for the patient to increase home health care hours. The letter stated the patient was currently in the hospital admitted due to worsening hypercapnic respiratory failure from restrictive lung disease. The provider noted the patient was a fall risk due to her visual problems and was at high risk for serious injury or even death due to continuous need for anticoagulation. Lastly, the provider recommended a minimum of 12 hours of supervision for assistance with all activities of daily living (ADLs). On the same date, the provider appealed the denial decision. The patient and family appealed the denial decision. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week. 

The services are medically necessary. There is documentation from the patient's medical provider of medical necessity of increased PCA services. The patient has legal blindness and requires assistance with walking, locomotion, and all other ADLs and Instrumental activities of daily living (IADLs). The patient requires maximum assistance specifically with walking, locomotion, transfer toilet, and toilet use. The patient therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient would require PCA services outside of all of the time that she has informal help. Because the patient has 24-hour care needs the plan should not have utilized a tasking tool to estimate PCA service hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. 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, CDPAP services 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 her own home.