Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Congestive Heart Failure.
Treatment:  Home Health Care (increase in home health/personal care assistance hours).

The health plan denied the request for home health care (an increase in home health/personal care assistance hours).  The health plan's determination is overturned.

The patient is a male with past medical history of congestive heart failure, hypertension, hyperlipidemia, atrial fibrillation on chronic anticoagulation, coronary artery disease, carotid artery stenosis, permanent pacemaker, chronic kidney disease, pressure ulcers of bilateral heels, low back pain, neuropathy, abnormality of gait, dependent edema, urinary incontinence, depression, insomnia and diabetes mellitus type 2, who had been hospitalized with subsequent transfer to rehabilitation facility with a plan to discharge to home. Occupational therapy notes  noted the patient to need set up assistance with dressing upper body, partial/moderate assist with dressing lower body, supervision/touching assistance with toilet transfer and toilet use, minimum assistance with bed mobility, substantial/maximum assistance with bathing/showering, and set up help for eating at the time of discharge from occupational therapy. Physical therapy notes noted dynamic standing was fair, transfers needed supervision, able to ambulate with rolling walker and stand by assistance 40 feet, patient would live at home with support from others at the time of physical therapy (PT) discharge. A note from PT stated the patient was able to transfer to stand with contact supervision and ambulate with rolling walker with contact supervision/contact guard. Nursing notes from rehabilitation stated the patient had a fall getting out of wheelchair alone, went to get up out of bed alone, and reaching for something on bedside tray and fell. The health care agent for the patient provided a letter stating the patient is not able to perform stand, transfer, ambulate without moderate to maximum assistance. The letter noted an original request for 2-12-hour aides to provide 24-hour assistance, 7 days/week. The letter also noted the patient needs to be repositioned every 1-2 hours due to heart failure to prevent skin breakdown and sepsis.

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

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

Yes. The patient has multiple chronic conditions with hospitalization and rehabilitation stay. According to the rehabilitation occupational therapy (OT) and physical therapy (PT) notes the patient needs assistance with all activities of daily living (ADL) tasks except eating (set up only). 

The patient has congestive heart failure with chronic lower extremity edema with diuretic use and it is not feasible for patient to avoid urination in the night-time hours, even with the reduction of fluid intake. The patient requires at least limited assistance with toilet transfer, locomotion, walking, and bed mobility. The patient had three falls in the rehabilitation facility when he attempted to perform some of these activities alone. The patient is on chronic anticoagulation and is at a higher risk for severe injury following a fall. An increase in consumer directed personal assistance services (CDPAS) hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ IADLs (instrumental activities of daily living). The plan incorrectly stated the patient can move about his bed on his own when the OT notes from rehabilitation noted the patient requiring minimum assistance. 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, CDPAS services to total 56 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 his own home.