Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hereditary spherocytosis. 
Treatment: Personal care assistance. 

The insurer denied Personal care assistance. 
The determination is overturned. 

The patient has a past medical history of hereditary spherocytosis and anxiety. The patient's primary care physician (PCP) provided a letter noting the patient's laboratory confirmed the condition of hereditary spherocytosis which caused debilitating pain, weakness, and occasional shortness of breath. The provider noted the patient has spent a tremendous amount of time consulting medical professionals and discussing treatment options as well as having multiple emergency room visits related to her condition. The PCP noted the patient would need close care with medical professionals and may be prone to increased episodes of symptoms due to the medical condition which is also impacted by stressors. The letter stated the patient's housing situation had been an additional stressor which had led to worsening symptoms and for improved health and management of her condition along with close care with physicians and surgeon she would need additional control of any environmental stressors and the physician requested the patient be assisted in her unstable housing as to provide more control over her health situation. 

The patient's hematology specialist noted the patient's diagnosis of hereditary spherocytosis and that the patient had become significantly more anemic over the past 2 years which has caused fatigue, loss of appetite, and weight loss noting the patient needed to consider splenectomy. The patient had been seen by her PCP via telemedicine with office notes stating the patient was having shortness of breath, fatigue, back pain, and abdominal pain related to spherocytosis. An office note from the PCP noted that the patient had increased pain with cooking and cleaning and the provider completed an M11Q form. 

The patient underwent an assessment assessing the patient at extensive assistance with the tasks of personal hygiene, ordinary housework, and shopping while limited assistance with the tasks of managing medication, stairs, transportation, and equipment management and independent with the tasks of managing finances, phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes from the assessment stated the patient had no informal help. 
The insurer sent a final adverse determination denial notice denying the request for personal care assistant (PCA) services. The denial stated the patient was medically stable and was able to complete daily tasks. The patient was seen with complaints of left knee swelling. The patient saw her psychiatrist noting the patient was considering a splenectomy offering support regarding patient's anxiety surrounding this procedure. The patient's PCP noted that the patient had a hereditary condition which caused her to suffer from an enlarged spleen, joint pains, anemia, and poor exercise tolerance and needed assistance with her activities of daily living like cooking, cleaning, groceries etc, and would benefit from a home health aide. The patient was seen by physical therapy (PT) for left knee pain. The patient was seen by orthopedics with a diagnosis of subluxation of the peroneal tendon of the left foot and patient was placed in immobilization brace to be worn for the next 6 weeks. The patient's PCP provided a letter requesting an external appeal of the denial decision. The letter stated the patient required home health services for cleaning and light housekeeping at home for a minimum of 2 hours/day, 5 days/week. In addition, the letter stated the patient had recently had an injury to her knee and ankle and was immobilized for the next 6 weeks. 
At issue is the medical necessity of personal care assistance services. 
The services are medically necessary. The patient's medical provider has documented the medical necessity of PCA services to assist the patient with activities of daily living (ADLs) and instrumental activities of daily living (IADL). The assessment tool performed indicates the patient requires extensive assistance with the tasks of meal preparation, ordinary housework, and shopping while limited assistance with the tasks of managing medication, stairs, transportation, and equipment management however, based on the information provided by the patient's medical providers, it underestimate the patient's care needs. The patient has no informal helper. The patient's care needs cannot be met solely with adaptive equipment and 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 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 her own home.