Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Degenerative arthritis
Treatment: Home health care (HHC) - level 2 personal care services (PCS) per 15 minutes increase to 63 hours/week
The insurer denied HHC - level 2 PCS per 15 minutes increase to 63 hours/week.
The determination is overturned.

The patient has a past medical history of gastroesophageal reflux disease (GERD), obesity, osteoporosis, stress incontinence, anxiety, depression, hypertension, urinary incontinence, coronary artery disease, osteoarthritis, cervical and lumbar degenerative disc disease, lumbar spondylosis, history of deep vein thrombosis (DVT), diastolic heart failure, arthritis of bilateral shoulders, chronic right foot stress fracture, lung cancer, gout, and carcinoid tumor who had been assigned personal care assistant (PCA) services 42 hours/week based on a telephonic assessment. The tasking tool estimated 31.5 hours/week.

There was a request to increase PCA services and the patient underwent an in person assessment assessing the patient at total assistance with the tasks of meal preparation and ordinary housework while maximum assistance with the tasks of stairs, shopping, and bathing. With the tasks of managing finances, managing medication, transportation, dressing lower body, walking, locomotion, transfer toilet, and toilet use, the patient was assessed at extensive assistance while limited assistance with tasks of phone use, personal hygiene, and dressing upper body. The patient was assessed at independent with the tasks of bed mobility and eating. Notes from the assessment stated that the patient lived with her spouse. The tasking tool estimated 41.83 hours/week.

The patient had an outpatient pulmonary medicine visit the with the office note stating the patient had a chronic cough, had been treated for a pseudomonal infection, had a recent sputum culture with Pseudomonas felt to be colonization, was going to have an updated computed tomography (CT) scan and Pulmonary Function Tests (PFTs).

The insurer sent an initial adverse determination denial notice denying the request for PCA services stating the recent assessment showed little change in comparison to the other assessment. The denial also stated the patient did not have any change in social circumstances, the patient had support from her family, and safety monitoring is part of the total personal care service (PCS) hours.

The patient's psychiatrist provided a letter noting the patient's diagnoses of depression and anxiety as well as confusion and forgetfulness. The letter also stated the patient was following up with her oncologist with a diagnosis of lung cancer resulting in being weak and tired with inability to climb stairs. In addition, the provider stated the patient needed assistance with all activities of daily living (ADLs) and the current number of hours put her at risk since there is not enough coverage in a day. Lastly, the letter stated the patient needed four more hours of services per day.

The patient's primary care provider (PCP) sent a letter stating it was their medical opinion that the patient needed additional 4 hours a day of home health due to coronary artery disease, diastolic heart failure, and difficulties with walking due to severe arthritis. The patient's physical medicine and rehabilitation (PM&R) provider sent a letter stating the patient experienced chronic low back pain that radiated into her buttock and down her leg with associated weakness and lack of balance. In addition, the letter stated the patient used a Rollator or assistive device as her walking tolerance was limited to less than 1 block. Lastly, the provider stated the letter was in support of the patient's appeal of the denial of services for an increase to 63 home health care (HHC) hours/week. The patient's own appeal paperwork stated her breathing was not good, she was very weak, her legs buckled, her aide leaves at 1 PM and the patient has difficulty taking care of herself.

The insurer sent a final adverse determination denial notice stating that given the patient's relatively stable function despite the patient's multiple medical conditions it was medically necessary to continue to provide 46 hours of care per week which was 10 percent (%) more care hours then the tasking tool estimated. The patient had an office visit with the PM&R provider who sent a letter stating that the patient required home care throughout the day and evening and required an aide to assist her with ambulation and toileting at unscheduled times throughout the day and evening. The letter also stated the patient lived with her spouse who was not physically capable of providing the patient assistance to meet her personal care needs on a daily/regular basis. Lastly, the letter stated the patient had no formal or informal supports to provide her with assistance.

Care logs were provided noting assistance throughout the aide's shift. The patient's spouse provided a letter in support of the patient's request for increased PCA services noting he was unable to provide any assistance with the patient's activities due to his own physical difficulties and health issues. The letter also noted there were no other family members or friends of the patient who were able and willing to provide assistance with the patient's daily activities. The patient's healthcare advocate provided a letter requesting external appeal of denial decision. At issue is the medical necessity of HHC - level 2 PCS per 15 minutes increase to 63 hours/week.

Yes, the services are medically necessary.

The patient's medical providers, including her PM&R and PCP, documented the medical necessity of increased PCA services. The plan noted in its denial the patient did not have a significant change from the previous assessment; however, the patient required at least extensive assistance with walking, locomotion, transfer toilet, and toilet use. Therefore, the patient had unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The plan assumed that the patient has informal help outside of the currently assigned PCA hours. The patient's spouse is unable to provide informal help and there are no other sources to provide formal or informal help. The required increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met with adaptive equipment and medical supplies alone. 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 63 hours/week are medically necessary for this patient. PCS 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.