Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular disorder-other-tremor
Treatment: Home health care
The health plan denied the increase in Personal Care Aid services 12 hours per day, 7 days  to total 84 hours per week as not medically necessary. 
The denial is overturned in whole.

The patient has past medical history of diabetes mellitus type 2, diabetic neuropathy, double vision, tinnitus, hearing loss, benign positional vertigo, lumbar radiculopathy, tremor, migraine, bladder incontinence, vitamin b12 deficiency, obstructive sleep apnea, dementia, gastroesophageal reflux disease, obesity, asthma, hypertension, osteoarthritis and hyperlipidemia who had been assigned Personal Care Assistant(PCA) services 6 hours/day, 7 days/week to total 42 hours/week based on an assessment tool. The patient's neurologist saw the patient via telemedicine with office note documenting patient's multiple medical diagnoses and complaints of short term memory loss as well as dizziness with imbalance. The patient's neurologist provided a letter stating the patient's underlying diagnoses as well as the patient's difficulty walking, continued pain, numbness and stiffness of the legs, low back pain, as well as slowness of movement due to extensive degenerative changes of the spine. The letter also stated the patient has a fine action tremor that worsens with stress and activity. In addition, the letter stated the patient has worsening short term memory and forgets to take his medication, forgets appointments, and which task he wanted to accomplish at a given moment. Lastly, the letter stated due to the patient's physical and cognitive limitations and severity and persistence of his symptoms, a home health attendant should be present no less than 12 hours/day, 7 days/week. The patient had a new telemedicine assessment tool assessing the patient at total assistance with managing medication while maximal assistance with tasks of meal preparation, ordinary housework, and shopping. The patient was assessed at extensive assistance with tasks of managing medication, phone use, stairs, transportation, bathing, dressing lower body, and toilet use while limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, and transfer toilet.  The patient lives alone in 1 bedroom apartment. The daughter visits daily after PCA hours as she worries about his safety.
An approval of PCA services 7 hours/day, 7 days/week to total 49 hours/week was given to the patient.

The requested health service of increase in Personal Care Worker (PCW) Services: 12 hours per day, 7 days per week is medically necessary for this patient. The patient has documented worsening of chronic medical conditions. The patient's neurologist notes the medical necessity for increased PCA hours. The patient needs at least limited assistance with all tasks except eating and bed mobility. The patient would need PCA services outside of the time he has an informal helper. He has unscheduled needs over a continuum of time. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) / Instrumental activities of daily living (IADLs). Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines an increase in PCA services to 12 hours/day, 7 days/week to total 84 hours/week is medically necessary. 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 his own home.