Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure/CHF.
Treatment: Home Health Care/personal care aide (PCA) hours 2-12-hour split shifts, 7 days a week .
The health plan denied the requested increase in personal care aide (PCA) hours to 2-12-hour split shifts, 7 days a week as not medically necessary.
The denial is: Overturned.

The patient is a female with a past medical history of coronary artery disease, hyperlipidemia, hypertension, atrial fibrillation, chronic anticoagulation, congestive heart failure, obesity, gastroesophageal reflux disease, chronic oxygen therapy, constipation, osteoarthritis, anemia, depression, urinary incontinence, and bowel incontinence who was hospitalized following a fall and was subsequently transferred to rehabilitation with 2 further hospitalizations and a diagnosis of COVID. Prior to the patient's hospitalization, she had personal care aide (PCA) services 8 hours a day, 7 days/week, but there was a request to increase PCA services and the patient underwent an assessment, assessing patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, and locomotion while maximum assistance with tasks of managing finances, bathing, dressing upper/lower body, and toilet use. The patient was assessed at extensive assistance with tasks of managing medication, phone use, personal hygiene, and bed mobility while limited assistance with task of eating. It was noted that tasks of locomotion and transfer toilet did not occur. Notes from the assessment also stated the patient had moderately impaired cognitive skills, utilized a wheelchair or scooter for locomotion, and had no informal helper. 

The patient's medical provider at rehabilitation provided a letter stating that prior to her admission the patient was capable of getting in and out of bed, transferring, ambulating short distances with a walker, and was able to complete all activities of daily living (ADLs), however, upon admission to the facility the patient required moderate assistance with bed mobility, maximum assistance for transfers, and was only able to ambulate 5 feet with a rolling walker with maximum assistance. The provider noted the patient had been participating in intensive rehabilitation program including physical and occupational therapy and the patient had made limited improvements as a result of the therapy program. In addition, the provider stated the patient's current functional status fluctuated, based on her becoming short of breath and having swelling in her upper extremities. The provider noted the patient required anywhere from minimal to moderate assistance with bed mobility, moderate to maximum assistance with transfers, and required moderate to maximum assistance with all ADLs. The provider also noted that at times the patient required maximum assistance with repositioning in bed, the patient had compromised safety awareness during standing and ambulation, and required continued cueing for safe completion of all tasks. In addition, the provider stated the patient was impulsive with compromised safety and was a high risk for falling and injuring herself without constant 24-hour supervision.

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

Yes, there is documentation of worsening physical functioning following multiple hospitalizations and a rehabilitation stay. 
The patient requires assistance with all ADLs and instrumental activities of daily living (IADLs). The patient's healthcare advocate noted the patient was not able to reapply her oxygen when it did come off, which had occurred during the night. 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 2-12 hours split-shift/day, 7 days/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.