Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Hypertension
Treatment: Home Health Care
The health plan denied the requested increase in personal care hours. 
The health plan's determination is overturned.

The patient is a male with a past medical history of hypertension, colon cancer, urinary incontinence, hyperthyroidism, anxiety, severe osteoarthritis of the knees, and dementia who had been assigned personal care assistance (PCA) services 6-1/2 hours/day, 7 days/week with an increase in PCA services to 8 hours/day, 7 days/week. At the assessment the patient had been assessed at total assistance with tasks of ordinary housework, managing finances, stairs, transportation, and locomotion while maximum assistance with tasks of meal preparation, managing medications, shopping, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of phone use, personal hygiene, dressing upper body, walking, transfer toilet, toilet use, bed mobility and eating. Notes from the assessment stated the patient was diagnosed with osteoarthritis and cognitive decline which cause pain, forgetfulness, weakness, and fatigue. It also noted the patient used his walker when ambulating and he could only walk about 20 feet without needing to take a rest. The assessment notes also stated the patient had to be pushed in the wheelchair over the last 3 days and the patient needed PCA to physically complete cleaning after toilet use. There was a request to increase PCA services and another telephonic assessment was performed, assessing the patient at assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, and locomotion while maximum assistance with tasks of managing medication, bathing, personal hygiene, dressing upper/lower body, walking, transfer toilet, and toilet use. With tasks of phone use, bed mobility, and eating the patient was assessed at extensive assistance. 

The patient's care advocate noted the patient was in urgent need of overnight hours, was incapable of taking care of his daily needs on his own, needed to use the bathroom 3-5 times per night, and could not turn in bed or get into and out of bed unassisted and was at high risk for developing decubitus ulcers. 
At issue is the medical necessity of the requested increase in personal care hours.

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

Yes, the patient has documented worsening functional and cognitive status. The patient has chronic and progressive medical conditions of osteoarthritis and dementia. The patient no longer has informal help from his wife. The patient had an increase in PCA care needs with tasks of meal preparation, shopping, personal hygiene, dressing upper body, walking, transfer toilet, and toilet use when comparing the telephonic assessments. 

The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living/instrumental activities of daily living. 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 12 x 12 hours/day, split shift, 7 days/week, to total 168 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 his own home.