Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke/CVA
Treatment: Home Health Care
The health plan denied the request for increase in home health care. 
The health plan's determination is overturned.

The patient is a male with a past medical history of cerebrovascular accident (CVA) x 3 with residual right hemiplegia and severe dysarthria, hypertension, coronary artery disease, hyperlipidemia, benign prostatic hyperplasia (BPH) with urinary incontinence and urinary frequency, depression, asthma, chronic obstructive pulmonary disease (COPD), chronic kidney disease, dementia, hearing loss, anemia, and gastroesophageal reflux disease (GERD). The patient was hospitalized in the Intensive Care Unit (ICU) with a COVID-19 infection. The physical therapy (PT) and occupational therapy (OT) notes from rehabilitation noted the patient required assistance with locomotion, transferring, toileting, oral hygiene, showering/bathing, dressing upper/lower extremity, bed mobility, and toilet transfer. The patient was subsequently transferred to another facility. There was a request to increase personal care assistance (PCA) service hours and the patient had a telephonic assessment tool performed, assessing the patient at total assistance for tasks of ordinary housework and maximal assistance with tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of managing finances, phone use, personal hygiene, dressing upper body, locomotion, walking, transfer toilet, toilet use, and bed mobility while limited assistance with task of eating. The notes from this assessment state the patient lives with his wife in a three bedroom home, has stairs to enter living quarters (with chair lift on premises), is non-ambulatory and utilized wheelchair for locomotion, is wheeled by others, is not safe to be alone, would need assistance in the event of an emergency, aide at facility assists with all tasks of daily living, needs assistance getting in and out of shower/bath so usually receives bed bath, is frequently incontinent, needs assistance to change diaper, needs assistance for personal hygiene after toileting and incontinence episodes, has meals pureed, and that his wife is unable to participate in his care. 

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

Yes, the patient had documented medical conditions with worsening functional status following his hospitalizations. The patient's OT/PT providers indicated the patient needed assistance with all activities of daily living (ADLs). The patient's discharge summary from the rehab facility indicated the patient required assistance with repositioning in bed, ambulating, eating, toileting and personal hygiene. The patient has unscheduled and unpredictable care needs that occur over a continuum of time which the insurer did not consider when making a decision for PCA service hours. The patient's assessment indicated the patient was non-ambulatory and wheelchair bound but once home he was able to ambulate with one person assist and walker. 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 his or her own home.