Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, cerebral infarction, chronic pain, dysphagia, gastroesophageal reflux disease (GERD), hypertension (HTN), hypothyroidism, mixed incontinence, rheumatoid arthritis, muscle weakness, and diabetes
Treatment: 80 Hours per Week Consumer Directed Personal Assistance Program
The insurer denied the 80 Hours per Week Consumer Directed Personal Assistance Program.
The denial is overturned. 

This female patient has conditions including cognitive impairment, cerebral infarction, chronic pain, dysphagia, gastroesophageal reflux disease (GERD), hypertension (HTN), hypothyroidism, mixed incontinence, rheumatoid arthritis, muscle weakness, and diabetes. The patient is appealing reduction of personal assistance services (PAS) hours from 80 to 56 hours per week.  

The patient lives in a private house. Her son assists with directing care. Assessment performed shows minimally impaired cognition and functional status: total dependence with meal preparation and housework; maximal assistance with shopping and toilet use; extensive assistance with managing medications, phone use, bathing, dressing, locomotion, and toilet transfer; limited assistance with personal hygiene and bed mobility; and supervision with eating. She can ambulate 15-149 feet with a walker and assistance. She requires two person assist to ambulate steps and leave home. She uses a wheelchair outdoors. She is frequently incontinent of bladder and occasionally incontinent of bowel. She had a fall when trying to transfer out of bed to commode. There are handwritten notes showing the patient gets up at nighttime to use the bathroom. The recent assessment compared to the previous assessment shows no change in functional status.  

Yes, the proposed treatment is medically necessary.

Medically necessary services are those which are:
1) safe 2) effective 3) generally accepted national standard of medical practice 4) not provided primarily for convenience of the patient or the practitioner 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

A letter from the provider is appealing the reduction in PAS hours, stating the patient is wheelchair bound and requires assistance with activities of daily living (ADLs) as already accounted for in the most recent assessment. The letter notes the patient has a new diagnosis of gout.

Personal care services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services. This patient is appealing a decrease in PAS hours from 80 to 56 hours per week. The patient has multiple chronic medical conditions and requires assistance with walker and wheelchair for locomotion. She had a recent fall when attempting to transfer from bed to commode. Assessment performed shows the patient requires assistance with all ADLs and instrumental activities of daily living (IADLs), with the exception of eating where she requires supervision. She requires limited assistance with bed mobility and personal hygiene. Otherwise, she requires a higher level of assistance with remaining ADLs and IADLs. The patient is incontinent of bowel and bladder. There are reports of assistance with toileting throughout the day. The assessment performed does not show improvement or change in functioning compared to the previous assessment performed. The patient requires significant assistance with mobility, ADLs and IADLs. Her functioning has not improved over the four months between assessments to support reduction in PAS hours. The approved 56 PAS hours per week are inadequate to meet the member's needs with ADLs and IADLs as noted above. The proposed PAS at 80 hours per week is medically necessary.