Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Osteoarthritis. 
Treatment: Home Health Care. 
The insurer denied an increase in personal care hours to 72 hours per week. 
The denial was overturned. 

The patient is a female with a past medical history of Alzheimer's disease, anxiety, depression, coronary artery disease, osteoarthritis, urinary incontinence, hypertension, and hyperlipidemia who had been assigned Consumer Directed Personal Assistance   Program (CDPAP) based on a telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of managing medication, shopping, and transportation. The patient was assessed at extensive assistance with tasks of managing finances while limited assistance with tasks of phone use, stairs, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. There was a request to increase CDPAP/PCA (personal care assistance) services and the patient underwent another telephonic assessment assessing the patient at total assistance with tasks of ordinary housework and managing finances while maximum assistance with tasks of meal preparation, managing medication, stairs, and shopping. The patient was assessed at extensive assistance with tasks of phone use, transportation, bathing, and dressing upper/lower body while limited assistance with tasks of personal hygiene, walking, locomotion, transfer toilet, toilet use, bed mobility and eating. 

The insurer sent final adverse determination denial notice denying request to increase CDPAP/PCA services. 

The patient's primary care physician (PCP) provided a letter requesting an increase in hours of home care due to her rapidly deteriorating mental state, physical health, and functional status. The PCP letter noted the patient had poor functional status, resides alone without any assistance, has reduced mobility, and requires a walker or human assistance to walk. The provider noted the patient has urinary incontinence in which she wears a diaper and requires multiple daytime and nighttime changes of soiled diapers. 
At issue is the increase of Personal Care Aide Level 2 and CDPAP (12 hours (hrs) per day - 5 days per week, 4 hrs per day - 3 days per week, for a total of 72 hrs per week) for medical necessity.

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

The requested health service/treatment of Personal Care Aide Level 2 and CDPAP (12 hrs per day - 5 days per week, 4 hrs per day - 3 days per week, for a total of 72 hrs per week) is medically necessary for this patient.

The patient has documented chronic and progressive medical illnesses of Alzheimer's dementia and osteoarthritis with a documented decline in mental and physical functional status. The patient requires at least limited assistance with all ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The patient had an increase in assistance needs with tasks of managing finances, phone use, stairs, dressing upper/lower body, and eating. The patient lives alone and requires assistance outside of the approved hours of CDPAP/PCA services to assist with unpredictable and unscheduled care needs. The patient's needs cannot be met with current CDPAP/PCA services in combination with adaptive equipment and medical supplies. 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.

Therefore, the Personal Care Aide Level 2 and CDPAP (12 hrs per day - 5 days per week, 4 hrs per day - 3 days per week, for a total of 72 hrs per week) is medically necessary.