Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Home Health Care. 
The insurer denied 24 hours a day 7 days a week split shift personal care services. 
The denial is overturned.

The patient is a male with past medical history of congestive heart failure (CHF), hearing loss, age-related cognitive decline, urinary incontinence, stool incontinence, atrial fibrillation on chronic anticoagulation, colorectal cancer, and Hodgkin's lymphoma who had been assigned Personal Care Assistance (PCA) services with a mutual case with his wife.

The health plan sent final adverse determination denial notice denying request to increase PCA services to 24 hours/day, split shift, 7 days/week. The patient's neurologist provided a letter requesting an increase in personal care services as medically necessary and in order to meet all of the patient's personal care needs. The provider noted the patient was prescribed Lasix which was giving the patient increased toileting frequency, the patient required total assistance with activities of daily living, the patient lived with his wife and they each required personal care services that were at times simultaneous but also divergent, the patient did not have informal support, the patient's nighttime needs for assistance were frequent and often extended and medication management for the patient's sleep disturbance had been ineffective or was incompatible with other conditions for which he was treated. The patient's healthcare advocate requested an external appeal of denial decision.
The subject under review is the medical necessity for the personal care services 24 hrs. x 7 days a week (split shift).

the requested service is medically necessary for this patient.
There is documentation of the patient's worsening physical functioning following the diagnosis of Hodgkin's lymphoma and colon cancer. The patient's medical provider has documented medical necessity of increased PCA services. Although the patient has a mutual case with his wife, they both have unpredictable and unscheduled care needs that span a continuum of time, and the health plan did not formulate a plan to meet these unpredictable and unscheduled care needs. The patient's care needs are frequent, especially with toileting and incontinence cares given the use of diuretic medication and the side effect of diarrhea from his cancer treatment. The patient has 24 hour care needs, therefore, a task based tool should not have been used to calculate the patient's hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient's daughter noted there is not a bedroom or sleeping space for a live-in aide. The patient has a history of skin breakdown and requires frequent turning and repositioning. The patient's care needs in the overnight hours are such that a live-in aide would not be able to obtain 5 hours of uninterrupted sleep. 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.