Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease.
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 dementia, osteoarthritis, urinary incontinence, gastritis, osteoporosis, severe sleep disturbance, coronary artery disease, and hyperlipidemia who had been assigned personal care assistance (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week based on assessment tool performed.  At the assessment the patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximal assistance with tasks of managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, waking, locomotion, transfer toilet, and toilet use. There was a request to increase PCA hours to 12 hours split shift, 7 days/week, to total 168 hours/week. The patient had a telephonic assessment performed with no change in assistance needs compared to the earlier assessment tool. The notes from the assessment noted the patient had severely impaired cognitive skills and her activities of daily living (ADL) status had deteriorated. In addition, the assessment stated the patient's sister was not able to help care for the patient due to her own health issues. The patient's sister is not able to sleep at night because of the patient's care needs overnight. The patient's primary care physician (PCP) wrote a letter requesting and increase in personal care services as medically necessary in order to meet all of the patient's needs. The letter further outlines the patient's medical diagnoses and the patient's need for total assistance with tasks of bathing, grooming, ambulating, dressing, and eating. In addition, the PCP letter stated the patient needs ambulatory assistance with walker and wheelchair, sleeps less than 5 hours nightly which would not permit a period of five hours of uninterrupted rest for her nighttime care giver, and the patient's sister is not able to continue caring for the patient when the home health aid is not present. 

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

Yes, the patient has progressive chronic medical problems documented by the patient's PCP. The patient's PCP provided medical necessity for PCA services, split-shift due to the patient's need with assistance with bathroom overnight and care needs overnight do not permit a period of five hours of uninterrupted rest for nighttime caregiver. The patient no longer has informal help from her sister due to her sister's own medical conditions. The patient requires assistance with all ADLs/IADLs (instrumental activities of daily living) based on telephonic assessment tool. An increase in PCA hours to 24 hours, split shift, is not solely for safety and supervision but to assist the patient's ADLs/IADLs, specifically personal hygiene, transfer toilet, toilet use, walking, and locomotion in the overnight hours. The patient's care needs would not allow a PCA 5 hours of uninterrupted sleep. 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, an increase in PCA services to 12 hours/day, split shift, 7 days/week to total 168 hours/week is medically necessary. 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.