Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure disorder.
Treatment: Personal care aide- 84 hours/week, consumer direct, 1 client.
The insurer denied personal care aide- 84 hours/week, consumer direct, 1 client.
The insurer's determination is overturned.

The patient has a past medical history of obesity, seizure disorder, and diabetes mellitus and had been assigned Consumer Directed Personal Assistance Program (CDPAP) services following an assessment assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, stairs, transportation, bathing, and dressing lower body. With tasks of personal hygiene, dressing the upper body, walking, locomotion, transfer toilet, and toilet use the patient was assessed with limited assistance while supervised with tasks of bed mobility and eating. The patient was assessed at set up only for phone use. The task-based tool estimated a need for 32.28 hours of services per week. The assessment stated the patient had a supportive family and lived with his mother, brother, and grandmother who can assist as needed.
There was a request to increase CDPAP services and the patient underwent an assessment noting the patient needed total assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing medication, bathing, personal hygiene, dressing upper/lower body, toilet use, toilet transfer, walking, and locomotion. The patient was assessed under supervision for the task of eating. The assessment tool calculated 22.06 hours/week. Notes from this assessment task-based tool stated the patient was moderately impaired cognitively. There was an appeal of the denial decision.
The insurer sent a final adverse determination denial notice denying a request to increase CDPAP services stating the patient would continue at 56 hours/week. The denial stated the insurer did not get information from the patient's doctor that his condition had changed after his most recent assessment nor did they get information from an epilepsy specialist showing the doctor's plan to better control the patient's seizures. The insurer suggested splitting up hours to meet personal care needs. The denial also stated services were not provided for safety and supervision and the patient could consider moving into a nursing home for long-term care.

The patient's primary care physician (or provider) (PCP) provided a letter on behalf of the patient to document the medical necessity of increased home health hours for the management of multiple chronic conditions. The provider also stated the patient had multiple breakthrough seizures daily with the home health aide catching the patient from falling and the patient has had multiple falls when the home health aide is off of duty. Lastly, the provider stated per his medical judgment the patient required at least 16 hours of home health aide services per day, 7 days/week.
The patient's neurologist provided a letter stating the patient had refractory frontal lobe epilepsy with bilateral anterior inferior frontal lobe gliosis and encephalomalacia and because of these conditions the patient had seizures. The letter stated the patient's seizures last typically 3 to 5 minutes and the patient has difficulty with breathing for about 5 to 10 minutes afterward. The neurologist also stated the patient had recently been diagnosed with diabetes which has impacted his behavior as he has been staying up late and waking up very early in the morning and has not been taking his medications. The neurologist also noted the patient needs assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) and it was his medical opinion that the patient needed at least 12 hours/day, 7 days/week of home care support.

At issue is the medical necessity of personal care aide- 84 hours/week, consumer direct, 1 client.

The patient has a complex history of recurrent seizures which he follows regularly with a neurologist. His neurologist noted that since the patient was diagnosed with diabetes his behaviors have changed and he is staying awake later and getting up in the morning he needs assistance with ADLs during this time. The patient's neurologist and primary care physician (or provider) (PCP) documented the medical necessity of increased CDPAP services. The patient's assessment underestimated his assistance needs with the number of hours they calculated on the task-based tool as he had an increase in assistance needs with most tasks compared to the prior assessment but had a significant decrease in the number of hours per week calculated, 22, compared to 32. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with the safe completion of activities of daily living (ADLs)  and instrumental activities of daily living (IADLs).

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, CDPAP services 84 hours/week are medically necessary for this patient. 

Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in his own home.