Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory. 
Treatment: Home Health Care. 
The insurer denied increase in PCA HHC (Home Health Care) level 2 hours to 84 per week. 
The denial is overturned. 

The patient is a female with past medical history of hypertension, congestive heart failure, severe aortic stenosis, diabetes mellitus type 2 with neuropathy/retinopathy, hyperlipidemia, chronic inflammatory demyelinating polyneuropathy, insomnia, anxiety, depression, cervical cancer, urostomy, bowel incontinence, repeated falls, obesity, history of T2 and L3 spinal fractures, cervical spinal stenosis with radiculopathy, and lumbar radiculopathy who had been assigned Personal Care Assistance (PCA) services at 42 hours/week and underwent an assessment tool over the telephone assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of transportation, bathing, and dressing lower extremity while limited assistance with tasks of managing finances, managing medication, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use. With the task of phone use the patient was assessed at set up with phone use and independent with tasks of bed mobility and eating. The notes from this assessment stated the patient had "child/child in-law" as informal helper. The patient's PCA services were increased to 49 hours/week. The subject under review is the medical necessity for the requested Home Care/Personal Care HHC Level 2 Personal Care services, per 15 minutes increase to 84 hours per week.

The health plan's determination is overturned.

Yes, the request to increase hours to 84 hours per week is medically necessary for this patient. The patient has multiple medical problems with documented decline in functional status. The patient has had multiple recent hospitalizations with documentation of worsening aortic stenosis to a point at which surgical repair has been recommended. The patient has chronic inflammatory demyelinating polyneuritis as well as neuropathy from her diabetes causing limitations to her functional abilities. In addition, the patient has retinopathy and macular edema with vision loss limiting her functional abilities. The patient does not have an informal helper outside of the time that the PCA is present. The patient has assistance needs with all activities of daily living (ADLs) except for bed mobility and eating. The patient has unscheduled and unpredictable care needs over a continuum of time. The patient needs assistance with emptying urostomy and changing diapers with history of bowel incontinence. 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 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.