Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Osteoarthritis
Treatment: Home Health Care
The health plan denied the requested increase in personal care assistance hours. 
The health plan's determination is overturned.

The patient is a female with a past medical history of osteoarthritis, oxygen dependent chronic obstructive pulmonary disease (COPD), dementia, coronary artery disease, urinary incontinence, osteoporosis, hypertension, gastroesophageal reflux disease (GERD), and a pressure ulcer of the left heel who had been assigned personal care assistance (PCA) services 3.5 hours/day, 7 days/week, to total 24.5 hours/week based on an assessment tool performed via telephone, assessing the patient at maximum assistant with tasks of meal preparation, ordinary housework, managing medication, and equipment management while extensive assistance with stairs and transportation. The patient was assessed at limited assistance with managing finances, bathing, and dressing upper body/lower body while supervision with tasks of walking, locomotion, transfer toilet and bed mobility. The patient was assessed at set up only for phone use and independent with personal hygiene, toilet use, and eating. The patient was hospitalized  for right ankle cellulitis. The patient was then hospitalized with a COVID-19 infection. There was a visiting nurse note stating the patient was at increased risk for falling, required someone to assist the patient with grooming, required assistance with upper and lower body dressing, was unable to use the shower or tub without the assistance or supervision of another person, was unable to get to and from the toilet without assistance, required assistance with maintaining toilet hygiene, was unable to transfer herself, was only able to walk with supervision or assistance of another person at all times, and was unable to feed herself. 

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

Yes. The patient had documented decline in functional and cognitive status following hospitalization for a COVID-19 infection. The patient had worsening in her ADL and Instrumental activities of daily living (IADL) assistance needs as documented in the assessment tool, showing a higher level of assistance needs with meal preparation, ordinary housework, managing finances, phone use, stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these care needs. The patient's care needs cannot be met with current approved PCA hours and/or adaptive equipment and/or medical supplies. The patient lives alone and does not have informal help for the entirety of time for which she does not have PCA hours. The requested increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/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 24 hours/day, live-in,7 days/week, to total 168 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.