Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung disease/Incontinence/Urinary Bladder Control
Treatment: Home Health Care/Personal Care Assistant 45 hours/Week
The health plan denied the requested increase in personal care assistant hours as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with a past medical history of urinary incontinence, bowel incontinence, coronary artery disease, gout, hypertension, lupus, chronic obstructive pulmonary disease (COPD) with oxygen dependence, chronic steroid use, anxiety, bipolar disorder, diabetes mellitus type 2 with insulin use, chronic kidney disease, obstructive sleep apnea, obesity, hypothyroidism, and atrial fibrillation who had been assigned consumer directed personal assistant program (CDPAP) services 31 hours per week. The patient had a follow up visit with his endocrinologist  regarding his diabetes. The patient had a follow up visit with his primary care physician (PCP). The patient had a follow up visit with his pulmonary medicine specialist with an office note stating the patient was using 5 liters of oxygen and was using a home continuous positive airway pressure (CPAP) machine. There was a request to increase CDPAP services and the patient underwent an assessment, assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing medication, stairs, shopping, transportation, and equipment management while extensive assistance with tasks of managing finances, bathing, dressing lower body, and toilet use. With task of dressing upper body, the patient was assessed at limited assistance while supervision with the task of eating. The patient was assessed at set up assistance with task of phone use and independent with tasks of walking, locomotion, transfer toilet, and bed mobility. Notes from assessment stated the patient had a decline in activities of daily living (ADL) status over the last 90 days, had a decline in overall self-sufficiency in the last 90 days, and had no informal help. A Mini-Mental State Examination (MMSE) was 21/30. The insurer sent an initial adverse determination denial notice denying request to increase CDPAP services. The patient's medical provider supplied Department of Health (DOH) form 4359, documenting the patient could not walk around the house, was unable to shower, was unable to cook, was unable to dress himself due to shortness of breath, used a cane or walker to help him walk longer distances, had bowel and bladder incontinence, and requested an increase in "caretaker hours". The insurer sent a final adverse determination denial notice denying request to increase CDPAP services, stating there was enough time to help the patient with her activities. The insurer recommended the patient utilize her hours over the week flexibly. Lastly, the insurer stated services benefits are not provided for general safety and supervision.
At issue is the medical necessity for the requested increase in personal care assistant hours to 45 hours/week.

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

Yes. There is documentation from the patient's medical provider of a request for increased CDPAP services on DOH 4359. The plan's own assessment noted the patient required maximum assistance with equipment management while extensive assistance with toilet use. The patient has no informal help. The plan's own assessment also noted a decline in ADL status and a deterioration of overall self-sufficiency in the last 90 days. The patient has unpredictable and unscheduled care needs that span a continuum of time. The requested increase in CDPAP services is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living (ADLs)/Instrumental activities of daily living (IADL). 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, CDPAP services 45 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 his own home.