Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post Traumatic Stress Disorder (PTSD), Anxiety
Treatment: Personal Care Aide Services
The insurer denied.
The determination is upheld.

This is a female patient with a medical history notable for post-traumatic stress disorder, anxiety, depression, obesity, and type 2 diabetes. The patient and her care team requested personal care aide services, and this request was denied by the health plan. This denial is the subject under review.
The patient's caseworker provided a letter of support for this appeal. The letter states that the patient was recently removed from a domestic violence situation and was not prepared to speak with the assessor during her Uniform Assessment System (UAS). Therefore, they feel that the assessment that was performed was inaccurate and that the denial of services was not reflective of her true level of need. They state that she has attestations from her physicians which detail her needs more accurately.
The patient's clinical psychologist provided a letter of support for this appeal. They have been treating the patient for the past 4 years. She has a history of psychiatric hospitalization. They say that the patient makes poor decisions which place her in dangerous situations secondary to borderline personality disorder features. The letter states that she is ambulatory and able to engage in self-care.
Medical records were provided for review. The records detail office visits and emergency department visits for the last several years. There was no discussion regarding any unmet personal care needs.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient's expressed goals of care were to have assistance with wound care, help going outside, bathing, shopping, housework, and emotional support. The patient was cognitively intact with independent cognition. For her instrumental activities of daily living, she was independent for all. For her activities of daily living, she was independent for all. She prepared meals for herself and cleaned her home independently daily for the previous three days. She denied any difficulties at that time. She is continent of urine and stool. At issue is the medical necessity of Personal Care Aide Services.

The requested health service of Personal Care Aide Services has not been demonstrated to be medically necessary for this patient.
The patient's assessment states that she is able to complete all Instrumental activities of daily living (IADLs) and activities of daily living (ADLs) without any assistance. The medical records provided were extensive, but they do not provide any discussion regarding which personal care tasks the patient is not able to complete on her own. The letter from her caseworker states that she was not forthcoming with all the areas that she requires assistance, but does not detail which personal care tasks she is not able to complete independently. The physician notes do not comment on this either. Personal care services cannot be approved for safety monitoring or for companionship. Therefore, it has not been clearly demonstrated that the request for personal care aide services is medically necessary for the patient.