Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
Treatment: Home care/personal care HHC (home health care) - level 2 personal care services per 15 minutes increase from 35 to 70 hours per week.

The insurer denied Home care/personal care HHC (home health care) - level 2 personal care services per 15 minutes increase from 35 to 70 hours per week.  The determination is overturned.

The patient has a past medical history of coronary artery disease, congestive heart failure, hypertension, gout, benign prostatic hyperplasia (BPH), osteoarthritis, hearing loss, back pain with sciatica, recurrent falls, and abnormality of gait and mobility, who had been assigned personal care assistant (PCA) services 5 hours/day, 5 days/week, to total 25 hours/week based on assessment tool performed assessing the patient at total assistance with tasks of ordinary housework, managing finances, and shopping while maximum assistance with tasks of meal preparation, stairs, and transportation. The patient was assessed at supervision with task of bathing, set up with task of phone use, and independent with tasks of dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating.

There was a request to increase PCA services, and the patient underwent telephonic assessment tool  assessing the patient at total assistance with meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing medication, phone use, stairs, transportation, bathing, dressing lower body, transfer toilet and toilet use. The patient was assessed at limited assistance with tasks of managing finances, walking, and locomotion while independent with tasks of personal hygiene, dressing upper body, bed mobility and eating. Notes from the assessment stated the patient used a rollator walker, fell, had support from his daughter-in-law, son and daughter.

The insurer sent initial adverse denial determination notice denying request to increase PCA services to 45 hours a week but partially denying with approval for 35 hours/week. The denial further stated that the  assessment showed no change in activities of daily living within the last 90 days and no change in overall self-sufficiency. It also stated that there was no change in social circumstances and the patient had a supportive family. Lastly, this denial stated plans were not required to include safety monitoring as a separate task for fall prevention and pain management.

The patient's primary care physician (PCP) provided a letter recommending PCA services 8 hours/day, 5 days/week, and 5 hours/day 1 day/week. The patient's daughter-in-law provided a letter requesting an appeal of the denial decision. The daughter-in-law's letter stated that the over the last 12 to 18 months the patient had required additional assistance with activities of daily living (ADLs). This letter also stated it was impossible for the family to be there every evening to assist the patient, and having an aide 8 hours a day would ensure his safety and guarantee he was getting his meals and medications. The insurer provided a final adverse determination denial notice denying the request to increase PCA services to 45 hours/week and approving services 35 hours/week.

The patient's family provided an appeal of denial of increased services stating the patient needed additional assistance, and it was difficult for the patient to be on his own all day. The patient's PCP provided M 11 Q form stating the patient suffered from chronic lumbago with sciatica, neuralgia and required extensive assistance with transfers and toilet transfers and lower body dressing and PCA services were medically necessary during waking hours equivalent to 10 to 12 hours/day.

The insurer sent an initial adverse determination denial notice stating the patient and/or provider requested an increase in PCA services to 70 hours/week. The insurer denied the request to increase services to 70 hours/week. This denial stated that the assessment showed no change in activities of daily living within the last 90 days and no change in overall self-sufficiency. In addition, it stated that there was no change in social circumstances and that the patient had a supportive family. Lastly, it stated a plan assessments are not required to include safety monitoring as a separate task for falls.
There was another appeal form filled out stating the patient is forced to wear wet diapers for an extended period of time often 12 to 18 hours daily and the family has been forced to secure additional personal care services to ensure toileting and toilet transfer needs beyond the 6 hours of care provided daily by PCA. The patient's healthcare advocate provided a letter requesting a fast-track internal appeal of the plans denial of requested increase in PCA services.

The insurer sent a final adverse determination denial notice denying the request for increased PCA services stating patient did not meet criteria and the request was not medically necessary. This denial letter stated the same reasons for denial of requested increasing PCA services as previous initial adverse determination denial notice. The patient's PCP appealed denial decision. The patient's healthcare advocate provided a letter stating the patient was bedbound for 18 hours/day due to his inability to get up from a lying position. This letter further stated the patient's PCA arrives at 8 AM and leaves at 2 PM, Monday through Friday, and 8 AM to 1 PM on Saturday with no services on Sunday. The healthcare advocate requested an external appeal of the denial decision. 

At issue is the medical necessity of home care/personal care HHC- level 2 personal care services per 15 minutes increase from 35 to 70 hours per week. 

The services are medically necessary. The patient has documented chronic progressive medical conditions of osteoarthritis, back pain with sciatica, and worsening functional capacity. The assessment performed via telephone showed increased assistance needs with meal preparation, phone use, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. The telephonic assessment underestimated his care needs for tasks of managing finances, stairs, and transportation as his assistance needs decreased compared to the prior assessment with documented worsening functional status. The patient had unpredictable and unscheduled care needs that span a continuum of time, and the insurer did not document a plan to meet those unpredictable and unscheduled care needs. The family is unable to provide all care/support outside of the hours of PCA. The patient's PCP provided documentation of medical necessity for increased PCA hours. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ Instrumental activities of daily living (IADLs). The patient's care needs cannot be met with current PCA hours and/or adaptive equipment and/or medical supplies. 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 10 hours/day, 7 days/week, to total 70 hours/week are medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.