Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Memory Impairment
Treatment: Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week
The insurer denied Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week.
The determination is overturned.

The patient has a past medical history of rheumatoid arthritis, osteoarthritis, cognitive impairment, atrial fibrillation, hypertension, congestive heart failure, coronary artery disease, diabetes mellitus (DM) type 2, fibromyalgia, chronic pain, anemia, deep venous thrombosis, chronic kidney disease, and urinary incontinence who had been assigned personal care assistant (PCA) services 48 hours/week based on an assessment tool. At this assessment the patient was assessed at total assistance with task of ordinary housework and maximum assistance with tasks of meal preparation, stair use, and shopping. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, transportation, bathing, dressing upper/lower body and transfer toilet while limited assistance with personal hygiene and toilet use. The patient was assessed as independent with tasks of walking, locomotion, bed mobility, and eating. Another assessment noted the patient had been receiving 48 hours/week of PCA services but was no longer attending adult day care two days per week and needed more help in her home. The patient lives alone in an apartment. Using the tasking tool, the patient was assessed at 23.5 hours/week following the earlier assessment. The patient was hospitalized with resultant cardioversion. She had another assessment tool performed due to the need for more assistance. The patient was noted to have an oxygen tank and concentrator in her apartment. The patient was assessed at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of phone use, stair use, and transportation. The patient was assessed at limited assistance with tasks of managing finances, managing medication, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility and independent with task of eating. The tasking tool calculated 29.83 hours/week. Both assessments noted the patient had a child or child in-law as informal helper.

The patient's primary care physician provided a letter noting the patient's past medical history and that the patient's medical conditions had deteriorated with increased multi-joint pain, progressive memory decline, inability to stand up from bed or chair, the need to be observed taking medication, and the need for assistance with bathing, dressing, and cooking. The prognosis for improvement was felt to be poor and an increase in home health aide hours was recommended.

The patient's rheumatologist noted that the patient is unable to dress herself due to swelling in the joints, is unable to eat on her own having to be fed on a regular basis, is unable to go to the bathroom on her own and needs to increase hours of assistance due to disabling condition and decrease in mental status. The patient's cardiologist provided a letter stating the patient has generalized weakness, unsteady gait and dizziness, and is at high risk for falling. The cardiologist noted the patient's conditions have worsened and the patient has a complex medication regimen requiring compliance and supervision. The cardiologist recommended an increase in home care assistance due to multiple comorbidities and to assure her safe and independent living. The insurer provided final adverse determination denial notice, denying the request to increase PCA service hours to 84 hours/week but did a partial overturn with approval of 63 hours/week stating these hours should be sufficient to meet the member's personal care needs. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week.

The requested services are medically necessary. The patient has documented progressive cardiac, neurologic and rheumatologic conditions but the later assessment tool indicated improvement in most of the activities of daily living (ADL) and instrumental activities of daily living (IADL) tasks (except walking and locomotion). The assessment tool specifically underestimated the patient's care needs for tasks of managing medication, as the patient's cardiologist noted the patient was unable to manage her complex medication regimen. In addition, the patient was assessed as independent with eating but her rheumatologist noted she was unable to feed herself. The rheumatologist also noted the patient required significant assistance with tasks that used her hands due to significant pain and deformity; these tasks would include personal hygiene, bathing, dressing upper/lower body, and toilet use. The patient's medical providers documented worsening and progressive medical conditions for which the assigned hours for PCA services did not meet the patient's needs with a request for 84 hours/week to meet her care needs. 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.