Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Home Health Care - 24 hours per day split shift
The insurer denied increase in services to 24 hours per day split shift. 
The denial is overturned. 

The patient is a female with a past medical history of dementia, coronary artery disease, anemia, congestive heart failure, depression, hypertension, hyperlipidemia, insomnia, urinary incontinence, and bowel incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 56 hours/week based on the assessment performed telephonically. 

The insurer provided initial adverse determination partially denying services with an increase to 70 hours/week. The insurer provided final adverse determination denial notice denying request to increase Personal Care Assistant (PCA) services stating it was not medically necessary to increase the patient's hours. The denial stated the personal-care hours were currently authorized in the amount, duration, and scope necessary to meet the patient's personal care needs and hours beyond those currently authorized would be for safety monitoring, which is not a covered benefit under the personal care services program. The patient was hospitalized with COVID-19 (Coronavirus 2019) infection, colitis, and acute metabolic encephalopathy with a transfer to rehabilitation facility. The patient was discharged from the rehabilitation facility, with discharge notes stating the patient required one person assistance for toileting and balance and guidance help for walking. The patient's healthcare advocate appealed the insurer's denial decision. The subject under review is the medical necessity for the increase in services.

The health plan's determination is overturned in whole.

The request for increase in services to 24 hours per day split shift is medically necessary for this patient. The patient has a documented decline in cognitive and physical functioning by her family, her medical provider, and with the comparison of the assessments. Furthermore, the patient was hospitalized with subsequent rehabilitation stay since the time of her assessment with documented ongoing care needs. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient has a history of dementia with resultant insomnia which causes erratic sleep patterns and despite treatment by her psychiatrist, the patient still is awake at night requiring assistance with walking, locomotion, transfer toilet, toilet use, and incontinence cares. The patient's assistance needs in the overnight hours would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/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.