Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Kidney Failure/ESRD
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 past medical history of osteoporosis, spinal stenosis, chronic kidney disease, urinary incontinence, gastroesophageal reflux disease (GERD), hyperlipidemia, hypertension, coronary artery disease, age-related physical debility, mild cognitive impairment, asthma, benign neoplasm of the brain, and repeated falls who had been assigned personal care assistance (PCA) services 8 hours/day, 5 days/week, and 7 hours/day, 1 day/week, and 5 hours/day, 1 day/week, all to total 52 hours/week. The patient's primary care physician (PCP) provided a medical request for home care (M11-Q) stating the patient needed at least 12 hours of home health aide services daily with progressive confusion. The M11-Q also noted the patient has uncontrolled hypertension and end stage renal disease (ESRD) and takes medication throughout the day and at night to control her medical conditions and needs assistance with managing medication. There was a request to increase PCA services and the patient underwent a telephonic assessment noting the patient at total assistance with tasks of ordinary housework and shopping while maximum assistance with tasks of meal preparation, stairs, and transportation. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and eating while limited assistance with task of bed mobility. Notes from the assessment noted the patient lives alone and had a fall when alone in the evening. The plan sent notice that the patient would be approved for PCA services 7 hours/day, 7 days/week, to total 49 hours/week. The plan sent appeal decision notices stating denial of the request to increase PCA services, recommending a recliner with seat lift and bed cane. The plan noted increase in PCA service time is not for safety and supervision. 

At issue is the medical necessity of the requested increase in personal care services.

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

The patient has documented progressive medical conditions of spinal stenosis, chronic kidney disease and cognitive impairment. The patient has a need for medication management outside of the currently assigned PCA hours. The patient requires at least limited assistance with all activities of daily living/instrumental activities of daily living (ADLs/IADLs) tasks. The patient has unscheduled and unpredictable care needs over a continuum of time and the plan failed to document a plan to meet these unscheduled and unpredictable care needs. The plan did recommend a recliner with seat and bed cane which would not replace the needs the patient has requiring assistance with a PCA. The patient specifically requires at least extensive assistance with personal hygiene, walking, locomotion, transfer toilet, toilet use, and incontinence cares. The request for increase PCA hours was not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Considering all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7days/week, to total 84 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.