Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Home Health Care

Diagnosis: Vertigo
Treatment: Consumer Directed Personal Care Assistance Services
The insurer denied Consumer Directed Personal Care Assistance Services: 5 Hours per Day, 7 Days per Week (Monday through Sunday), Total of 35 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of depression, s/p Covid 19 infection, urinary incontinence, chronic UTI (urinary tract infection), vertigo, chronic pain, constipation, and GERD (gastroesophageal reflux disease) who had been assigned Consumer Directed Personal Care Assistance Services (CDPCAS). The patient had an assessment tool performed via telephone assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing medication, stairs, and transportation. With tasks of managing finances, phone use, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use, the patient was assessed at limited assistance while independent with tasks of bed mobility and eating. Notes from this assessment stated the patient had no informal help, and walked with a cane or held onto walls and furniture for support. Vertigo symptoms affected her activities of daily living (ADL) and Instrumental activities of daily living (IADL). Since her COVID-19 infection, she has been feeling more tired with activity intolerance, short of breath, and cough, and was not able to bend down. There was a request to increase CDPAS and the patient underwent an in-person assessment tool assessing the patient at maximum assistance with ordinary housework and shopping while extensive assistance with meal preparation, stairs, and transportation. With tasks of managing finances, bathing, dressing lower body, walking, and locomotion, the patient was assessed at limited assistance while supervision with tasks of managing medication and toilet use. 

Consumer Directed Personal Care Assistance Services: 5 Hours per Day, 7 Days per Week (Monday through Sunday), Total of 35 Hours per Week is medically necessary for this patient.
There is documentation of functional decline and vertigo symptoms following COVID-19 infection in March 2020. The patient has unpredictable episodes of vertigo making it difficult for her to perform ADLs and IADLs. The patient has no informal help. The patient requires at least limited assistance with walking and locomotion. If the patient has increased vertigo symptoms, she requires more assistance with ADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPCAS is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Care Assistance Services: 5 Hours per Day, 7 Days per Week (Monday through Sunday) 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.