Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in Personal Care Worker Service to 84 hours. 
The denial is overturned in whole.

The patient is a male with a past medical history of hypertension, hyperlipidemia, coronary artery disease, diabetes mellitus type 2, multiple cerebrovascular accident (CVA)s, unstable gait, hypothyroid, cervical stenosis of the spine with myelopathy, depression, insomnia and prolonged hospitalization following coronavirus disease (COVID-19) infection who had been assigned patient care assistance (PCA) services 6 hours/day 7 days/week to total 42 hours/week based on telephonic assessment tool. Following this assessment, the patient's PCA hours were increased to 10 hours/day, 7 days/week to total 70 hours/week.
The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's medical diagnoses and that the patient had recently undergone a right ulnar nerve transposition of the elbow becoming more impaired and unable to utilize his right arm. In addition, the PCP letter noted the patient lived alone and had trouble completing his cooking, grocery shopping, laundry, and had become more dependent on home care assistance for these chores. 
The patient underwent another telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, equipment management, bathing, and dressing lower body. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer to the toilet, toilet use, and eating, while supervision with tasks of managing finances and managing medication. 
The patient saw his PCP with office notes stating the patient continued to appeal denial decision by insurer to increase PCA services and was referred to social worker at this visit.
At issue is an Increase in Personal Care Worker (PCW) Service to 7 days per week, 12 hours per day; 84 hours for medical necessity.

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

The requested health service/treatment of Increase in Personal Care Worker (PCW) Service to 7 days per week, 12 hours per day; 84 hours per week is medically necessary for this patient.
The patient's PCP provided a letter noting the patient's worsening physical functioning following right arm surgery and the assessment tool underestimated the patient's assistance needs. The PCP indicated worsening physical functioning yet the telephonic assessment showed less assistance needs with most tasks as compared to earlier, which would indicate an underestimation of assistance needs on the assessment. The patient lives alone. The patient requires assistance with all tasks except bed mobility. The patient has unscheduled and unpredictable care needs that span a continuum of time, and the insurer did not formulate a plan to meet these care needs. The requested increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADL)s. 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.
Therefore, the requested health service/treatment of Increase in Personal Care Worker (PCW) Service to 7 days per week, 12 hours per day; 84 hours per week is medically necessary.