Appeal type: Medical necessity
Decision: Overturned

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

The insurer denied an increase in Personal Care Worker services for medical necessity. The denial was overturned. 

The patient is a female with past medical history of Alzheimer's dementia, coronary artery disease, deep vein thrombosis (DVT), long term anticoagulation, gait instability, peptic ulcer disease, gastroesophageal reflux disease (GERD), urinary incontinence, hypertension (HTN), osteoarthritis, venous insufficiency, and vitamin B12 deficiency anemia. The patient's neuropsychiatrist provided a letter stating the patient's diagnosis of Alzheimer's dementia with psychosis. In addition, the letter further stated the patient required assistance with activities of daily living including getting up from bed, dressing, taking showers, and heating up food.
There was a request to increase her Personal Care Assistance (PCA) services and the patient underwent a telephonic assessment assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication and shopping, while extensive assistance with tasks of stairs, transportation, equipment management, bathing, and dressing her lower body. With tasks of phone use, personal hygiene, dressing upper body, toilet use, and eating, the patient was assessed at limited assistance while independent with tasks of walking, locomotion, transfer toilet, and bed mobility. 

The insurer provided final adverse determination denial notice partially denying request to increase PCA services by increasing to 4 hours/day, 7 days/week, to total 28 hours/week. The denial stated the requested increase in PCA services was not medically necessary and the patient did not meet criteria. 

The patient's healthcare advocate provided a letter requesting external appeal of denial decision stating medical necessity of increase in PCA hours. The letter from advocate further stated the patient's needs for PCA assistance had increased and the assessments completed underestimated her assistance needs. 

At issue is the medical necessity of Increase in Personal Care Worker (PCW) services to 7 days per week, 7 hours per day; 49 hours per week.

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

The requested health service treatment of Increase in Personal Care Worker (PCW) services to 7 days per week, 7 hours per day; 49 hours per week is medically necessary. 
There is documentation of worsening cognitive and physical functioning in this patient with chronic medical conditions of Alzheimer's disease and coronary artery disease. The patient had assistance needs with toileting which is an unscheduled and unpredictable care need that spans a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met with current hours and/or medical supplies, and/or adaptive equipment. The increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. 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 7 hours/day, 7 days/week, to total 49 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. 

Therefore, the requested service of Increase in Personal Care Worker (PCW) services to 7 days per week, 7 hours per day;49 hours per week is medically necessary.