Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System-COPD/Chronic Obstructive Lung Disease
Treatment: Home Health Care-Personal Care Aide -Level 2; 84 hours/week, 12 hours x 7 days. 

The health plan denied the increase in Personal Care Assistant hours as not medically necessary. 

The reviewer has overturned in whole the health plan's determination. 

The patient has a past medical history of chronic obstructive pulmonary disease (COPD), lung cancer, depression, and coronary artery disease. He had been assigned PCA (personal care assistant) services based on an assessment tool. A total of 30 hours was assessed. 

He underwent a reassessment assessing the patient with minimal independent cognition with memory problems. He was noted to be alert and oriented, no hearing or vision difficulties. He requires total dependence with the task of ordinary housework and maximal assistance for meal preparation. The patient was assessed at maximal assistance with the task of bathing, limited assistance for personal hygiene, extensive assistance for dressing upper body, dressing lower body, total dependence with locomotion, and maximal assistance for toilet use (noted to need 2+(plus) helpers or weight bearing support for greater than (>)50% of task), independent with bed mobility and limited assistance with eating. Uses a wheelchair. Activities of Daily Living (ADL) status was noted to have declined in the last 90 days, with no change in self-sufficiency. He has bladder frequently incontinent and bowel occasionally incontinent. Worsening incontinence in the past few weeks was noted with 8-10 pads needed daily. Toileting is completed in bed. A total of 31 hours was assessed. 

The patient's primary care provider (PCP) wrote a letter that stated that patient is a home bound male with multiple medical problems, lung cancer COPD, home oxygen, hypertension, depression, insomnia, low back pain, incontinence. The PCP notes that the patient requires total assistance for dressing, grooming, bathing, toileting, walking, eating, laundry, housekeeping, and requires 24hr care. A letter from patient's niece indicated that her uncle was bed-bound and gets dizzy when he moves. She also noted that he is incontinent and unable to change his diaper or get dressed and needs reminders with his medications. A letter from the patient's pulmonologist stated that the patient has worsening fibrotic interstitial lung disease and worsening of his disease and desaturates with minimal movement. 

The requested health service/treatment of Personal Care Aide-Level 2; 84 hours/week, 12 hours x 7 days is medically necessary for this patient. 

Based on the assessment, the patient requires assistance with housework, meal preparation, bathing, personal hygiene, dressing upper and lower body, locomotion, transfer toilet, and toilet use. On reassessment, he was noted with a decline in his ADL status and is basically home bound. Additionally, he has been noted to need maximal assistance for toilet use, needing 2+ helpers for transfers, and also incontinent requiring multiple pads a day. The requested increase in assistance was not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). Considering the 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, 12 hours x 7 days is medically necessary for this patient.