Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Hypertension/High Blood Pressure.
Treatment: Increase in Personal Care Assistance services to 98 hours per week.

The health plan denied the request for an increase in Personal Care Assistance services to 98 hours per week.  The health plan's determination is overturned.

The patient is a female with a past medical history of dementia, asthma, gastroesophageal reflux disease (GERD), hypertension, hyperlipidemia, coronary artery disease, atrial fibrillation, chronic anticoagulation, lower extremity edema, anxiety, depression, osteoarthritis, obesity, bilateral hammertoes, left lumbar radiculopathy, irritable bowel syndrome, insomnia, urinary incontinence, and bowel incontinence, who had been assigned personal care assistance (PCA) services 70 hours/week. The patient had worsening abdominal pain with diagnosis of irritable bowel syndrome. The patient had acute renal failure which improved with intravenous (IV) fluids. The patient had COVID 19 with a respiratory infection and a requirement of oxygen. There was a request at that time to increase PCA services and the patient underwent an assessment tool over the telephone, assessing the patient at total assistance with tasks of ordinary housework and managing finances, with maximum assistance with tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use while limited assistance with tasks of bed mobility and eating. Notes from the assessment stated the patient was moderately cognitively impaired, lived alone, overall self-sufficiency deteriorated, and had two or more falls in the last 90 days. 

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

Yes. The patient has chronic progressive medical conditions of dementia, urinary and bowel incontinence, low back pain, and coronary artery disease. The patient has documented worsening physical and mental functioning following acute renal failure and a COVID 19 infection. The patient requires at least some assistance with all activities of daily living/instrumental activities of daily living (ADLs/IADLs). The patient has unpredictable and unscheduled care needs over a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The 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 to total 98 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.