Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central nervous system/Neuromuscular disorder 
Treatment: Home Health Care 

The insurer denied increase to 84 hours per week personal care services. The denial is overturned in whole. 

The patient is a  female with past medical history of dementia, dysphagia, urinary and stool incontinence, atrial fibrillation, malnutrition, chronic hepatitis B, recurrent falls, bed bound status and degenerative arthritis of the spine/bilateral hips. She had been assigned personal care assistance (PCA) services 6 hours/day, 5 days/week and 5 hours/day, 2 days/week to total 40 hours/week based on assessment tool performed in the beginning of the year. This assessment noted the patient ambulated with a cane indoors and a rollator walker outdoors. The patient was assessed at total assistance for task of ordinary housework and maximal assistance with tasks of meal preparation, stairs, shopping, transportation, bathing and dressing lower body. She was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet and toilet use while assessed as independent with bed mobility and eating. 

Three months ago, the patient became ill with fever, weakness and decreased oral intake. She was treated with antibiotic empirically for urinary tract infection (UTI). The patient did not improve and was placed on home hospice with goals to provide comfort and avoid hospitalization. The patient's home health aides had quit due to concerns of COVID-19 and the patient's family provided 24 hour care. With ease in COVID restrictions family members were planning to return to work and would only be able to provide care to patient 8 pm to 8 am. There was a request for increased PCA hours to 12 hours/day, 7 days/week to total 84 hour/week. The patient's primary care physician (PCP) wrote a letter in support of increased PCA hours noting the patient was eating poorly, was barely able to stand, had memory loss and poor insight and required assistance with all activities of daily living. The letter also noted the patient spent most of her time in bed as she was not able to walk. There was another letter provided from PCP stating the patient needed to be spoon fed all meals, was confined to bed, was unable to dress or bathe herself and had pressure ulcers of the sacrum and ankle requiring frequent positioning and off-loading. This letter also noted they were trying to avoid an aide from hospice due to COVID pandemic in an attempt to limit the number of individuals in contact with the patient. The PCP requested an increase in PCA hours to 12 hours/day, 7 days/week to total 84 hours/week. 

The health plan's determination is overturned in whole. 

Yes, the requested personal care service 12 hours per day, 7 days per week for a total of 84 hours is medically necessary for this patient. 

The patient had a significant decline in her medical and functional status from prior assessment tool. The patient was bedbound while previously had ambulated with a cane or rollator walker. The patient requires being spoon fed while previously was independent with eating. The patient had been independent with bed mobility on assessment but was unable to reposition/turn in bed with development of sacral ulcer and right ankle ulcer. The patient's illness three months ago caused a significant change in her ability to perform activities of daily living (ADLs) now requiring total assistance with bathing, personal hygiene, dressing upper/lower body, transfer toilet and toilet use. The patient did not have an informal helper between the hours of 8 am and 8 pm.