Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Problems. 
Treatment: Home Health Care. 
The insurer denied Personal Care Services 24 hours a day 7 days a week split shift.  
The denial is overturned.

The patient is a male with past medical history of chronic obstructive pulmonary disease (COPD) with oxygen requirement and bi-level positive airway pressure (BiPAP) therapy, morbid obesity, chronic respiratory failure, right heart failure, hypertension, edema, hydrocele, and diabetes mellitus type 2 who had been admitted to the hospital with lower extremity edema and cellulitis. The insurer sent final adverse determination denial notice denying request to increase personal care assistance (PCA) services stating the patient's care needs could be met with the current services. The insurer recommended a bed cane to help move in and out of the bed. They recommended a bedside table to keep belongings near him. In addition, the insurer stated a live-in aide could help the patient with his care needs including position changes and assistance with toileting 1-2 times per night allowing the aide to obtain at least 5 hours of uninterrupted sleep in an 8-hour period. Lastly, the plan stated they did not provide time for companionship, safety supervision, or when there was no task being done. The patient appealed denial decision. The patient's medical provider appealed denial decision. With this appeal there was documentation that the patient required unscheduled assistance both day and night.

The health plan's determination is overturned in whole. 

The requested service of personal care services 24 hours a day, 7 days a week split shift is still medically necessary. There is documentation following the patient's two hospitalizations of worsening physical functioning. It is documented by the patient's medical provider that the patient had not been sleeping in his bed because he was unable to transfer for toileting, eating, and locomotion in the nighttime hours. This worsened his edema and created skin breakdown. The patient takes diuretic therapy for right heart failure and edema and when laying supine redistributes fluids at night causing increased urination. The patient requires assistance with toileting and incontinence care. 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 unpredictable and unscheduled care needs. The patient also needs assistance in the overnight hours with care needs due to severe shortness of breath from COPD with any activity and the patient requires at least limited assistance with all Instrumental activities of daily living (IADLs)/activities of daily living (ADLs). The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, 7 days/week, split-shift, 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.