Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Hypertension/High Blood Pressure.
Treatment: Home Health Care.
The health plan denied the requested increase in personal care hours as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with past medical history of osteoarthritis, chronic rotator cuff tear, cervical radiculopathy, memory loss, anxiety, hyperlipidemia, hypertension, osteoporosis, and urinary incontinence who had been assigned consumer directed personal care assistance (CDPAP) services 24 hours/week based on assessment performed, assessing the patient at extensive assistance with tasks of managing finances, managing medication, stairs, shopping, transportation, equipment management, bathing, dressing lower body, and bed mobility, while limited assistance with tasks of meal preparation, ordinary housework, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at set up only with the task of phone use and independent with tasks of personal hygiene and eating.  The patient saw her primary care provider again, with an office note stating the patient's mobility was largely limited by cervical radiculopathy, lumbar spine arthritis, knee pain, and shoulder pain and the patient was with urinary incontinence and cognitive decline and the patient would benefit from HHA (home health aide) 7 hours/day, 7 days/week. This office note also stated the patient was having a knee replacement. The patient saw her medical provider again with this office note stating the patient had fallen and hit her head and the patient would benefit from a home health aide for 7 to 10 hours/day, 7 days/week. On the same date as the office visit, the provider completed an appeal of the denial decision stating the patient was medically compromised due to her multiple medical problems, her diagnosis of frequent falls, gait dysfunction, shoulder bursitis, cervical radiculopathy, osteoarthritis of the knees, and requested an increase in care of 12 hours/day, 7 days/week.
At issue is the medical necessity for the increase in personal care assistance to 40 hours/week.

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

Yes. There is documentation from the patient's PCP of worsening cognitive and physical functioning. The patient will also be having a knee replacement. The patient requires assistance with all activities except for bed mobility and eating. The patient's informal caregiver is no longer able to provide the same level of assistance. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, CDPAP services, to total 40 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.