Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Deep Vein Thrombosis.
Treatment: Home Health Care.
The health plan denied the requested increase in personal care assistance hours due to the lack of medical necessity. 
The health plan's determination is overturned.

The patient is a female with a past medical history of deep vein thrombosis (DVT), osteoporosis, constipation, hypertension, urinary incontinence, gastroesophageal reflux disease (GERD), long-term anticoagulation, low back pain, hyperlipidemia, rheumatoid arthritis, and urinary urgency who had been assigned CDPAP (consumer directed personal assistance program) services 5 hours/day, 4 days/week and 8 hours/day, 1 day/week to total 28 hours/week. The patient had been hospitalized with a DVT of her right leg requiring a procedure to remove the clot. There was a request to increase CDPAP hours and the patient underwent a telephonic assessment tool assessing the patient at total assistance with the task of ordinary housework and maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with task of managing medication, stairs, transportation, bathing, dressing lower body, and toilet use while limited assistance with tasks of managing finances, equipment management, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet. With tasks of bed mobility and eating, the patient was assessed at independent. Notes from the assessment stated the patient had no informal helper, used a cane, Rollator and manual wheelchair, had difficulty with mobility and movement since recent surgery for DVT removal, was an increased fall risk despite no falls in the last 90 days, needed help getting in and out of the shower, and relied on CDPAP for all meal prep. The tasking tool estimated a need of 24.4 hours/week. The insurer provided an appeal decision notice stating the appeal was denied increasing CDPAP services to 5 hours/days, 7 days/week to total 35 hours/week. The denial of appeal further stated the patient's personal care tasks could still be done the time that had been provided during the current hours. The denial also stated the patient should follow-up with her doctor regarding the symptoms she was reporting and see her doctor to find out what was happening with her health.
At issue is the medical necessity of the requested increase in personal care assistance hours.

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

Yes, the patient has documented worsening in physical functioning following hospitalization with a DVT of the leg. The patient had surgical treatment to remove a blood clot. The tasking tool did not provide time for incontinence cares and the assessment tool noted the patient required help with toileting, transfer of toilet and changing of diaper and Chux up to 4 times per day. The patient does not have an informal helper to provide care outside of CDPAP hours. The patient requires at least limited assistance with all ADLs (activities of daily living) except bed mobility and eating. 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 5 hours/day, 7 days/week, to total 35 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.