Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD), urinary incontinence, hypertension, osteoarthritis, and coronary artery disease
Treatment: Home Health Care (Split shift) 
The insurer denied of Personal Care Aide Level 2: 12 hours/day, 7 days/week, 12 hours/day, 7 days/week (Split shift), for a total of 168 hours/week. 
The denial is overturned.

The patient is a female with past medical history of chronic obstructive pulmonary disease (COPD), urinary incontinence, hypertension, osteoarthritis, and coronary artery disease who had been assigned personal care assistance (PCA) services 4 hours/day, 7 days/week, to total 28 hours/week based on assessment performed via telephone  assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping with limited assistance with tasks of stairs, transportation, bathing, dressing upper/lower body, and toilet use. The patient was assessed at supervision with task of managing medication, walking, locomotion, and transfer to the toilet while set up help with managing finances. The patient was assessed as independent with tasks of phone use, personal hygiene, bed mobility, and eating. Notes from the assessment stated the patient lived at home and had informal help from her son. At that time, she was continent of urine.

The patient had a hospitalization with a diagnosis of right lung mass and was subsequently transferred to rehabilitation at which time she was dependent on oxygen and treated with bi-level positive airway pressure (BiPAP) therapy overnight. The patient underwent an assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing medication, shopping, transportation, and locomotion while maximum assistance with tasks of bathing, personal hygiene, dressing upper/lower body, walking, transfer to toilet, and toilet use. The patient was assessed at extensive assistance with task of bed mobility, supervision with task of eating, and set up with tasks of managing finances and phone use.

The insurer sent final adverse determination denial notice continuing to deny request to increase PCA services to 12 hours/day, 7 days/week, split shift, stating the increase to 49 hours/week would ensure that the patient's personal care needs would continue to be met appropriately.

At issue is the medical necessity of PCA Level 2: 12 hours/day, 7 days/week, 12 hours/day, 7 days/week (Split shift), for a total of 168 hours/week.

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

The requested health service/treatment of PCA Level 2: 12 hours/day, 7 days/week, 12 hours/day, 7 days/week (Split shift), for a total of 168 hours/week is medically necessary for this patient.

There is documentation of worsening physical functioning of the patient. The patient requires oxygen now for her chronic obstructive pulmonary disease (COPD). The patient has a lung mass for which she has denied evaluation and likely represented cancer. The patient requires at least maximum assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's unscheduled and unpredictable care needs. The patient has no informal help. The patient has documented skin changes of the diaper area requiring turning and repositioning at least every 2 hours. 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.

Therefore, the requested health service/treatment of PCA Level 2: 12 hours/day, 7 days/week, 12 hours/day, 7 days/week (Split shift), for a total of 168 hours/week is medically necessary for this patient.