Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision/Blindness.
Treatment: Home Health Care/Personal Care Assistance Services - a total of 42 hours a week.
The health plan denied the Home Health Care/Personal Care Assistance Services - a total of 42 hours a week as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with a past medical history of macular degeneration with legal blindness, chronic kidney disease, carpal tunnel syndrome, urinary incontinence, osteoarthritis, osteoporosis, hyperlipidemia, hypertension, diabetes mellitus type 2 with diabetic neuropathy, and iron deficiency anemia who was assigned personal care assistant (PCA) services 4 hours/day, 7 days/week following an assessment via telephone assessing the patient at maximum assistance with tasks of ordinary housework and shopping while extensive assistance with tasks of meal preparation, stairs, transportation, and equipment management. With tasks of managing finances, managing medication, phone use, bathing, dressing upper/lower body, and eating, the patient was assessed with limited assistance, while supervised with tasks of personal hygiene, transfer toilet, and toilet use. The patient was assessed as independent with tasks of walking, locomotion, and bed mobility. Notes from the assessment stated the patient had no informal help. There was a request to increase PCA services. The insurer sent an appeal decision notice stating the patient had asked for an increase in PCA services because she had problems with her left hand and could not use/move her hands, she was legally blind, she could not go to doctor's appointments or go out by herself, she needed more time and more assistance with walking, bathing, toileting, cooking, housework, going to appointments, shopping, using stairs, and crossing the street, she could not answer or dial her phone, she reported weakness of her hands and legs due to advanced age, she had no informal support or family and she lives alone, she reported some of her neighbor friends who used to help her had already passed away, and the patient had a brother who lived far away. Medical records from the patient's primary care physician (PCP) document the patient's medical diagnoses, medications, and past referrals. 
At issue is the medical necessity for the requested increase in PCA services to 42 hours per week.

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

Yes. The patient's assessment underestimated the patient's care needs. There was no time allotted to prepare dinner. In addition, the patient has had a change in her physical and social situation and therefore the previous assessment underestimated the patient's current care needs. The appeal decision notice stated the patient would be having another assessment, but this was not provided for review. The patient requires at least supervision for transferring toilet and toilet use and therefore the patient has unpredictable and unscheduled care needs that span a continuum of time. Furthermore, the patient has no informal help. 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 42 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in her own home.