Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory/Asthma. 
Treatment: Home Health Care. 

The health plan denied the requested increase in personal care assistant hours.
The health plan's determination is overturned. 

The patient is a female with a past medical history of urinary incontinence, hypertension, asthma, memory loss, wheelchair bound status, deep vein thrombosis (DVT)/pulmonary embolism (PE) with chronic anticoagulation, gastroesophageal reflux disease (GERD), and breast cancer who had been assigned personal care assistant (PCA) services 24 hours per week. There was a request to increase PCA services and the patient underwent an assessment assessing the patient at total assistance with tasks of ordinary housework, stairs, and shopping while maximum assistance with tasks of meal preparation, managing finances, transportation, bathing, dressing lower extremity, walking, and locomotion. With tasks of managing medication, phone use, personal hygiene, dressing upper body, transfer toilet, and toilet use the patient was assessed at extensive assistance, while limited assistance with tasks of bed mobility and eating. The patient was seen by her medical provider for an asthma exacerbation. On the same date, the provider filed a report stating the patient needed a home health aide at all times for minimal ambulation, monitor vital signs, diaper changing, was bedbound and required 24 hours of home health aide services. The patient's medical provider filed another report noting patient had gait abnormality, moderate asthma, was wheelchair bound and needed 24-hour service. The patient's medical provider completed another report stating the medical diagnoses of the patient and the patient required 24-hour home health aide services and had been hospitalized 3 times in the past year. The patient's primary care physician (PCP) provided a letter stating the patient was bedbound with a history of repeated falls and needed 24-hour home health aide secondary to memory loss, persistent dizziness, and pulmonary embolism. The patient's daughter provided a letter appealing denial decision stating the daughter lives with the patient and the daughter could no longer take care of the patient due to the daughter's own full-time work. The daughter noted the patient could not be left alone, the patient had severe respiratory problems, the patient had worsening memory, and had multiple falls. 

At issue is the medical necessity for the requested increase in personal care assistant hours.

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

Yes, PCA services 12 hours/day, 5 days/week, and 9 hours/day, 2 days/week to total 78 hours/week are medically necessary for this patient. 

There is documentation by the patient's primary care provider of the medical necessity of increased PCA services. There is documentation by the patient's PCP and the patient's daughter of worsening cognitive and functional status. The daughter is no longer able to provide informal support at the amount of time the patient requires assistance. The patient requires assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient has unscheduled and unpredictable care needs that span a continuum of time to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. 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, PCA services 12 hours/day, 5 days/week and 9 hours/day, 2 days/week to total 78 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.