Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous System/Neuromuscular Disorder.
Treatment:  Personal Care Services, 15 hours/day, 7 days/week.  

The insurer denied Personal Care Services, 15 hours/day, 7 days/week for medical necessity.  The denial was overturned in whole.

The patient has a past medical history of atrial fibrillation, hypertension, congestive heart failure, cerebral infarct, frequent falls, asthma, sciatica, osteoarthritis, bladder incontinence, chronic kidney disease, unstageable pressure ulcers, DM type 2, history of deep vein thrombosis (DVT), glaucoma, and gout.  The patient is bed confined and had been assigned personal care assistance (PCA) hours for 7 hours a day for 6 days a week and 6 hours a day for 1 day a week to total 48 hours a week.  The patient had a fall  with subsequent request for an increase in PCA hours.

The patient's primary care physician (PCP) provided a letter stating the patient needed an increase in hours with a home attendant.  The patient had an assessment tool performed via telephone assessing the patient at total assistance with tasks of ordinary housework and stairs, while maximal assistance with tasks of meal preparation, shopping, dressing lower body, transfer toilet, and toilet use.  The patient was assessed at extensive assistance with tasks of managing finances, managing medication, transportation, bathing, personal hygiene, and dressing upper body, while limited assistance with task of bed mobility.  The patient was assessed as independent with eating.  The notes from the assessment stated the patient was no longer ambulatory and had no informal helper.

The health plan sent final adverse determination letter stating the request to increase PCA hour to 15 hours a day, 7 days a week to total 105 hours a week was not medically necessary.  The letter stated the patient had a rollator to help move around her environment, but the assessment stated the patient was unable to walk.  Home physical therapy (PT) and a hospital bed was recommended.

The patient's  provider stated the patient required home visits due to multiple comorbidities that require considerable and taxing effort to leave home.  The PCP further stated the patient needs assistance with ambulating on her own and has the inability to reposition herself in bed.  This provider requested PCA hours for at least 12 hours a day, 7 days a week.  The daughter stated the patient is alone 12 hours a day and is unable to get up on her own and needs assistance with all activities of daily living.  The daughter noted the patient has pressure ulcers from being bed bound and needs assistance to be turned in bed, and the patient does not have an informal helper.  The patient's healthcare advocate noted the patient required 24-hour split-shift care, but the request for PCA services is 15 hours, as the family will provide informal support the other 9 hours.  The letter states the patient requires turning and repositioning every two hours to treat current ulcers and prevent new sores.  In addition, the patient's incontinence and the need for timed voiding and prompt diaper changes to prevent skin breakdown and infections.  The advocate notes the patient is prescribed Eliquis and is at risk for severe bleeding should she sustain a fall.

At issue is the medical necessity of Personal Care Services for 15 hours a day, 7 days a week.

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

The requested health service/treatment of personal care services, 15 hours a day, 7 days a week is medically necessary for this patient.

The patient had a fall with subsequent worsening functional status and worsening of chronic medical conditions.  The patient is bed bound with pressure ulcers and requires assistance with all activities of daily living (ADL) and instrumental activities of daily living (IADL).  She requires turning and repositioning every two hours.  The patient has unscheduled and unpredictable care needs over a continuum of time.  The patient requires 24-hour care, and, therefore, the Uniform Assessment System (UAS) should not have been used to determine the patient's PCA hours.  Even though the patient requires 24 hours of care per day, split shift, the family will be providing 9 hours of care per day; hence the request for 15 hours of PCA services per day.  PCA hours for this patient are not solely for safety and supervision but to assist the patient with safe completion of multiple ADLs and IADLs.  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.

Therefore, the requested service treatment of personal services, 15 hours a day, 7 days a week is medically necessary for this patient.