Appeal type: Medical necessity
Decision: Overturned

Diagnosis: arthritis, bladder incontinence, functional decline, hypertension, congestive heart failure, osteoarthritis
Treatment: Home Care / Personal Care HHC (home health care)- Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Live In)
The insurer denied Home Care / Personal Care HHC (home health care)- Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Live In). The health plan's determination is overturned.

The patient is a female with multiple comorbidities. She underwent an assessment which assessed her at total assistance with tasks of meal preparation, ordinary housework, and shopping while needing maximum assistance with managing finances, stairs, transportation, equipment management, dressing lower body, and transfer toilet. She was assessed at extensive assistance with tasks of managing medication, bathing, personal hygiene, dressing upper body, walking, locomotion, and toilet use while needing limited assistance with tasks of phone use and bed mobility. For the task of eating, she was assessed at independent. The tasking tool estimated she needed 37.5 hours of assistance per week. The patient was assigned 38 hours of Consumer Directed Personal Assistance Program (CDPAP) services per week.

The patient was hospitalized again with congestive heart failure and was discharged home on oxygen. There was a request to increase CDPAP services to 24 hours per day, live in, 7 days per week. She underwent another assessment which assessed her at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping and maximum assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing lower body, and toilet use. With tasks of personal hygiene, dressing upper body, walking, locomotion, and transfer to the toilet she was assessed at extensive assistance while needing limited assistance with tasks of bed mobility and eating. Notes stated she lived with her daughter and remained on oxygen. The patient was dependent on her daughter for instrumental activities of daily living (IADL) and activities of daily living (ADL).

At issue is the medical necessity for Home Care / Personal Care HHC (home health care)- Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Live In).
I overturn the health plan's determination, in whole.

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Live In) is medically necessary for this patient.

There is documentation from the patient's medical provider of worsening physical functioning and from the plan's own assessment of an increased need of assistance. The patient has assistance needs of at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time. The patient therefore has 24-hour care needs, and a tasking tool should not have been utilized to calculate personal care assistance (PCA) hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADL and IADL. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The insurer cannot assume the patient has informal support outside of currently assigned PCA services. 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 per day, (live-in)7 days per 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.