Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure (CHF)
Treatment: Home Health Care/Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week 
The health plan denied the requested Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week as not medically necessary. The health plan's determination is overturned.

The patient is a female with a past medical history of anxiety, depression, coronary artery disease, congestive heart failure (CHF), bladder incontinence, bowel incontinence, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, osteoarthritis, and hearing loss who had been assigned personal care aide (PCA) services 6-1/2 hours, 7 days a week, to total 45.5 hours/week, based on assessment, assessing the patient at total assistance with tasks of ordinary housework and managing finances while maximum assistance with tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, personal hygiene, and dressing upper/lower body. With tasks of walking, locomotion, transfer toilet, and toilet use, the patient was assessed at extensive assistance, while limited assistance with task of bed mobility. The patient was assessed at set up with the task of phone use and independent with the task of eating. The patient was hospitalized with a myocardial infarction, had a stent placement and was diagnosed with congestive heart failure. 

The patient was later admitted to hospice with a diagnosis of nutritional marasmus with failure to thrive. The note stated the patient had been slowly deteriorating with poor intake and persistent weight loss and noted generalized weakness and required assistance with all activities of daily living (ADLs). The patient's hospice provider sent a letter requesting an increase in PCA services, stating it was medically necessary and needed to meet the patient's personal care needs. The letter also stated the patient lived alone and her daughters were not able to provide daily assistance with activities of daily living. The hospice provider later sent another letter noting the patient was homebound.

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

The patient's hospice provided documented medical necessity of increased PCA services with documentation of the patient's worsening functional status with poor oral intake and weight loss. The patient requires assistance with walking, locomotion, transfer toilet, and toilet use and therefore, has unpredictable and unscheduled care needs that span a continuum of time. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (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 12 hours/day, 7 days/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.