Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Musculoskeletal/Orthopedic. 
Treatment:  Increase in Level 2 Personal Care Services to 84 hours per week. 

The insurer denied increase in Level 2 Personal Care Services to 84 hours per week.  The denial is overturned.

The patient is an female with past medical history of coronary artery disease, hypertension, diabetes mellitus type 2, urinary incontinence, gastroesophageal reflux disease (GERD), glaucoma, hypothyroidism, lumbar radiculopathy, osteoarthritis, and status post Covid 19 with residual weakness and fatigue, who had been hospitalized with urinary tract infection (UTI), hypertension, vomiting and Covid positivity. There was a request to increase personal care assistance (PCA) services and the patient underwent a telephonic assessment tool assessing the patient at total assistance with tasks of ordinary housework while maximum assistance with tasks of meal preparation, shopping, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, stairs, transportation, walking, locomotion, transfer toilet, and toilet use while limited assistance with tasks of phone use, personal hygiene, dressing upper body. With tasks of bed mobility and eating the patient was assessed as independent. Notes from the assessment stated the patient reported increased fatigue and weakness, is no longer able to take a shower, is only able to make a few steps with walker and assistance, uses urinal in the bed when home alone, has difficulty turning herself in bed and occasional assistance is required, and has poor endurance that limits physical performance. The health plan sent final adverse determination denial notice denying request to increase PCA services to 84 hours/week. 

The health plan's determination is overturned.

The requested services to increase personal care services to 84 hours a week is medically necessary for this patient.

The patient has chronic progressive medical conditions of osteoarthritis, coronary artery disease, glaucoma, macular degeneration, and diabetic retinopathy with a documented decline in cognitive and functional status following hospitalization for Covid-19. The patient had 2 assessment tools approximately 6 weeks apart showing an increase in assistant needs with meal preparation, shopping, personal hygiene, and dressing upper body. Notes from the assessments themselves, the patient's primary care provider, and the patient's son indicate that with several tasks her assistance needs are underestimated on the most recent assessment tool. The patient has unscheduled and unpredictable care needs that spanned a continuum of time. The plan assumed that the patient had informal help, but the patient's son lives an hour away and is only able to visit once a week. 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). The patient's care needs cannot be met with current hours and/or adaptive equipment and/or 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, home care/personal care HHC (home health care)-Level 2 Personal care services per 15 minutes, increase to 84 hours per week is medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.