Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease/GERD. 
Treatment: Home Health Care. 

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

The health plan's determination is overturned. 

The patient is a male with a past medical history of hypothyroidism, gastro-esophageal reflux, aneurysm of iliac artery, iron deficiency anemia, type 2 diabetes, and a foot ulcer.
The patient had been assigned PCA (personal care assistant) services based on an assessment tool assessing the patient with modified independent cognition with memory problems. He was noted to be alert and oriented, forgetful but able to reorient himself. He has no hearing or vision difficulties. He requires total dependence with task of ordinary housework and maximal assistance with meal preparation. The patient was assessed at total dependence with the task of bathing, maximal assistance with personal hygiene, dressing upper body, dressing lower body, walking, locomotion, transfer toilet, and limited assistance with toilet use, bed mobility and supervision with eating. He was noted with a decline in activities of daily living (ADL) status in the last 90 days, with a deterioration in self-sufficiency. He was also noted to have a foot ulcer. He is occasionally incontinent with bladder and is bowel continent. A total of 42 hours was assessed. 

The patient underwent a reassessment assessing the patient with minimally impaired cognition with memory problems. He was noted to be alert and oriented, forgetful but able to reorient himself. He has no hearing or vision difficulties. He requires total dependence with task of ordinary housework and maximal assistance with meal preparation. The patient was assessed at total dependence with the task of bathing, maximal assistance with personal hygiene, dressing upper body, dressing lower body, walking, locomotion, transfer toilet, toilet use, bed mobility and total dependence eating. He was noted with decline in ADL status in the last 90 days, with a deterioration in self-sufficiency. He was frequently bladder and bowel incontinent but had some control present. A total of 42.5 hours was assessed. 

The patient's primary care provider wrote a letter of medical necessity. It was noted that the patient requires home visits and is home bound, has an inability to reposition himself in bed, and is dependent on all ADLs and instrumental activities of daily living (IADLs)  Thus, increased hours are requested. The patient had a home visit by his primary care physician. It was noted that he had a loss of appetite and fatigue, and was also noted with skin discoloration, leg edema and joint deformities. 
A letter from patient's daughter and the night sleep logs provided, indicates that the patient is needing overnight care with a need for frequent turning and toilet care several times a night; the family unable to continue to provide overnight care. 

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

The assessment tool performed indicated the patient had increased assistance needs with several tasks, including, housework, meal preparation, bathing, dressing upper/lower body, locomotion, transfer toilet, and toilet use. It is also noted that patient has a foot ulcer, is incontinent and is requiring assistance with toileting through the night. He also requires assistance with bed mobility, thus requires turning to prevent decubitus ulcers. The requested increase in assistance was not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services of 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is medically necessary.