Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 

The insurer denied Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15-minute increase to 24 hours per day(live in). 
The denial is overturned. 

The patient is a male with past medical history of coronary artery disease, hypertrophic cardiomyopathy, chronic diastolic and systolic heart failure, osteoarthritis, gastroesophageal reflux disease (GERD), hypertension, benign prostatic hyperplasia (BPH), hyperlipidemia, spinal stenosis, peripheral neuropathy, Fuchs corneal dystrophy, and bladder incontinence who had been assigned patient care aide (PCA) services 9 hours/day, 7 days/week, to total 63 hours/week. The patient was admitted to the hospital and discharge summary noted private hire 24/7 live-in aide services. The patient saw ophthalmology documenting his diagnosis of vitreous floaters, Fuchs corneal dystrophy, brunescent cataract, and pseudoexfoliation lens capsule. There was a request to increase PCA services and the patient underwent an assessment, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, and transportation while maximum assistance with tasks of managing medication and dressing lower body. With tasks of managing finances, phone use, bathing, personal hygiene, dressing upper body, walking, locomotion, and toilet use the patient was assessed at extensive assistance while limited assistance with task of transfer to the toilet. The patient was assessed as independent with tasks of bed mobility and eating. The patient lived alone, used a Rollator walker with 1 assist, was paying out-of-pocket for 24 hours by 7 days a week (24/7) live-in services, and had informal help from child/child in law and friend. 

At issue is the medical necessity of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15-minute increase to 24 hours per day (live in). 

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

The requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15-minute increase to 24 hours per day(live in) is medically necessary for this patient. 

There is documentation of functional decline following hospitalization. The patient had 24/7 aide services at private pay since that time, with documentation provided from the aids of needed assistance outside of the currently provided PCA hours. The plan assumed the patient had informal support outside of the currently approved PCA hours which was not the case. The patient requires at least limited assistance with transfer to the toilet, toilet use, walking, and locomotion. The patient has significant activities of daily living (ADL) needs not just based on functional capacity but also on his severe vision loss. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these care needs. The requested increase in PCA services 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. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 24 hours/day, live-in, 7 days/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 his own home. 
Therefore, the requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15-minute increase to 24 hours per day(live in) is medically necessary for this patient.