Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes.
Treatment: Home Health Care-Personal Care Assistant.
The health plan denied the requested increase in personal care assistance hours due to the lack of medical necessity. 
The health plan's determination is overturned.

The patient is a male with a past medical history of type 2 diabetes mellitus, coronary artery disease, hyperlipidemia, osteoarthritis, dementia, and prostate cancer who had been assigned personal care assistance (PCA) hours 7 hours/day, 7 days/week, to total 49 hours/week following a hospitalization and rehabilitation stay. There was a request to increase PCA hours and the patient underwent an assessment tool, assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, phone use, transportation, bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use. The patient was assessed at limited assistance with tasks of walking, locomotion, and bed mobility while supervision with task of eating. The patient's house call physician provided a letter stating that due to chronic conditions the patient requires total assistance of one person with all his activities of daily living (ADLs) which include bathing, dressing, toileting, personal hygiene, meal preparation, medication management, and ambulation. The house call provider letter also stated the patient is not able to use assistive device to transfer or ambulate due to outward turning of both of his feet. In addition, the house call physician's letter stated the patient's chronic conditions had worsened and continued to deteriorate with assistance needs all hours of the day, including nighttime for incontinence and toileting. 

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

PCA services 24 hours/day, live-in, 7 days/week are medically necessary for this patient.
The patient has documented chronic and progressive medical diagnoses of dementia and osteoarthritis, as well as documented deformity of both feet rendering him unable to use assistive devices for ambulation. Per the assessment, the patient had assistance needs with all tasks except eating. According to the patient's house call provider, his daughter, his son, and his social worker, the patient has had worsening in his functional status since that assessment. The patient has unscheduled and unpredictable care needs over a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan assumed the patient had informal help from his children, but they are unable to provide informal help as documented in their letters. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ Instrumental activities of daily living (IADLs). 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 24 hours/day, live-in, 7days/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.