Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central nervous system/Neuromuscular Disorder
Treatment: Home Health Care 
The insurer denied increase in personal care hours to split shift 168 hours per week. 
The denial is overturned.

The patient is a female with past medical history of Alzheimer's disease, recurrent syncope, chronic obstructive pulmonary disease (COPD), status post Covid-19, implantable loop recorder, myelodysplastic syndrome, urinary incontinence, hypertension, hyperlipidemia, hypothyroidism, anemia, osteoarthritis, osteopenia, and stage IV renal failure who had been assigned Personal Care Assistance (PCA) service hours 12 hours/day, 7 days/week, to total 84 hours/week based on telephonic assessment tool performed. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, stairs, transportation, bathing, and dressing lower body. With tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while supervision with tasks of bed mobility and eating. Notes from the assessment stated the patient was moderately cognitively impaired, was able to recall 0 of 3 words, daughter reported patient wanders at night, and the daughter reported finding the patient's soiled underwear in patient's drawers.

The subject under review is the medical necessity for the increase in personal care assistance hours.

The health plan's determination is overturned in whole. 

The requested increase in hours is medically necessary for this patient.

Prior to the patient's fall, the patient's caregivers and medical providers had supplied letters supporting the patient's need for 24-hour care. However, the plan approved 12 hours/day, 7 days/week 2 days before she had a loss of consciousness with injury requiring current rehabilitation stay. The patient had recurrent undiagnosed syncope and had loop recorder implanted. The rehabilitation staff including providers, occupational therapy (OT), and physical therapy (PT) felt patient could be discharged to home with 24-hour, split shift, 7 days/week PCA services to assist with her activities of daily living. The patient has documented chronic and progressive medical illnesses of Alzheimer's, COPD, osteoarthritis, and renal failure with the diagnosis of COVID-19 infection during her rehabilitation stay causing increased weakness. There was documentation of cognitive and functional decline during her rehabilitation stay. The patient has unscheduled and unpredictable care needs that span a continuum of time. The patient has the medical condition of insomnia with assistance needs overnight to ambulate, eat, drink, transfer toilet, and with incontinence cares that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA hours 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). The patient's approved PCA hours, adaptive equipment, and medical supplies are not sufficient to meet all of her care needs. 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, split shift, 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.