Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis.
Treatment:  Increase in home health care hours.

The health plan denied the requested increase in home health hours.  The health plan's determination is overturned.

The patient is a female, who lives alone with past medical history of atrial fibrillation on chronic anticoagulation, coronary artery disease, hypertension, abnormality of gait, history of falling, chronic pain, neuropathy, osteoarthritis, varicose veins with history of venous ulcers, glaucoma, and age related cognitive decline, who had been hospitalized with perforated gastric ulcer with subsequent surgery.  The patient has been assigned personal care assistant (PCA) services 7 hours/day, 7 days/week to total 49 hours/week.  There was a request to increase PCA services and the patient had an assessment tool performed, assessing the patient at total assistance with meal preparation and ordinary housework while maximal assistance with tasks of stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, and bed mobility while assessed at limited assistance with task of eating.  There were no subjective notes in the assessment tool, mostly one word/scripted answers to the questionnaire.  The insurer sent a final adverse determination denial notice stating the service is not medically necessary.  The denial notice also stated the patient is able to ambulate, transfer, and toilet with assistance and with the use of an assistive device.  In addition, the denial notice stated the tasking tool indicated that 5.4 hours per day of service is sufficient to meet the patient's needs and complete tasks, and hours can be split, so some of the hours can be used in the evening while the patient prepares for bed.  The patient appealed adverse decision.  The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's past medical history and total hip replacement is recommended due to pain and limitation with activity but has been postponed due to COVID-19 pandemic.  The letter further states the patient is unable to function without substantial assistance due to pain and limited range of motion.

At issue is the medical necessity of the requested service.

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

Yes, the patient has multiple medical problems including progressive diagnoses of osteoarthritis and age-related cognitive decline.  The patient had a change in functional status with a request to increase PCA hours from 7 hours/day to 11 hours/day.  The patient lives alone and requires at least some assistance with all tasks as documented in Uniform Assessment System (UAS) tool.  The patient's PCP documents the need for assistance with all tasks, due to her medical conditions with worsening functional capacity related to her left hip pain secondary to osteoarthritis with current inability to have joint replacement due to COVID-19 pandemic.  The patient requires assistance with unscheduled and unpredictable needs such as walking, locomotion, transfer toilet, and toileting.  The patient would need PCA services for the hours that she is unable to have informal help.  The increase in PCA hours is not solely for supervision and safety but to assist the patient with safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL) tasks.  The tasking tool completed fails to document specific assistance needs with ADLs/IADL tasks.  The tasking tool underestimated the patient's care needs as it did not take into account unscheduled and unpredictable care needs (nor does it report if needs can be scheduled) and the time it takes to assist the patient with successful completion of ADL/IADL tasks.  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.