Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Home Health Care. 
The insurer denied increase in personal care assistance hours. The denial is overturned in whole.

The patient is a female with past medical history of constipation, urinary incontinence, hypertension, chronic kidney disease, carpal tunnel syndrome, dizziness, peripheral vascular disease, osteoarthritis, and hearing loss who had been assigned Personal Care Assistance (PCA) services 4 hours/day, 7 days/week, to total 28 hours/week based on assessment tool.

There was a request to increase PCA hours to 8 hours/day, 7 days/week, to total 56 hours/week and the patient underwent assessment over the telephone. Notes from the assessment stated the patient had no informal helper, was occasionally incontinent, was unable to prepare something to eat due to numbness and coldness of her hands, was frequently dropping objects due to carpal tunnel syndrome, had difficulty getting in and out of the tub, can use the commode without assistance and will have urinary incontinence if she is not in a room near the bathroom. In addition, the notes stated the patient transfers from sitting position to standing with the use of her walker occasionally needing assistance to stand and ambulate with wheeled walker with slow unsteady gait and is unable to stand for long due to shakiness of the legs. The patient's score on the Mini-Mental State Examination (MMSE) was 18/30. The tasking tool  assessed the need of 3.8 hours/day. This tasking tool indicated time for toilet use, transfer toilet, and walking occurred once daily.

The plan sent final adverse denial determination notice stating the requested increase in PCA hours was not medically necessary and the patient did not meet criteria. The denial letter also stated the patient was able to walk, transfer, and use a toilet with limited help and with the use of a rolling walker. In addition, the denial letter stated the patient was able to feed herself meals that were set up in advance by her aide. The letter also stated the patient's daily needs can safely be met by the current service hours. The plan also stated they are not required to include safety monitoring as a separate task when calculating hours.

The subject under review is the medical necessity for the increased hours.

The health plan's determination is overturned in whole.

Although the patient's assessment tool did not show significant change in assistance needs, the patient does not have any informal help as noted in the assessment tool and would need an increase in PCA hours due to her needed assistance with unscheduled and unpredictable care needs (walking, locomotion, toilet use, and transfer toilet). The tasking tool sheet calculated "one" episode of walking, toilet use and transfer toilet per day which would also underestimate her daily PCA care needs. The health plan did not document a plan to meet the patient's unscheduled and unpredictable care needs. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs)/instrumental activities of daily living (IADLs). Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 8 hours/day, 7 days/week, to total 56 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.