Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, coronary artery disease, type II diabetes mellitus, hyperlipidemia, osteoporosis, non-ST segment elevation myocardial infarction, 
chronic kidney disease, cerebral vascular accident, anemia, gastroesophageal reflux disease, vertigo, anemia, and insomnia
Treatment: Increase Personal Care Aide Hours from 7 Days 6 Hours per Week To 7 Days 9 Hours per Week for a Total of 63 Hours per Week
The insurer denied the Increase Personal Care Aide Hours from 7 Days 6 Hours per Week To 7 Days 9 Hours per Week for a Total of 63 Hours per Week.
The denial is overturned. 

This patient is a female with multiple medical conditions including hypertension (HTN), coronary artery disease (CAD), type II diabetes mellitus (DM), hyperlipidemia (HPL), osteoporosis, non-ST segment elevation myocardial infarction (NSTEMI), chronic kidney disease (CKD), cerebral vascular accident (CVA),  anemia, gastroesophageal reflux disease (GERD), vertigo, anemia, and insomnia.  The patient is appealing increase in personal care aide (PCA) hours from 49 to 63 hours per week.  

The patient lives alone in an apartment in a senior housing facility. Assessment performed shows minimally impaired cognition and functional status:  total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances, phone use, bathing, and lower body dressing; extensive assistance with managing medications, upper body dressing, walking, locomotion, and toileting; limited assistance with personal hygiene and eating; and independent with bed mobility.  Appeal letter from daughter states the aide's hours are 9AM - 4PM.  The daughter states that her mother needs overnight monitoring to manage medications.  She states her mother is noncompliant with frequency and dosage if not supervised.  She states her mother was admitted with acute colitis and hyponatremia.  An appeal letter from the doctor states the patient has complex medical conditions, history of stroke, instability, severe cervical stenosis, tympanic membrane perforation, hearing loos and weakened health conditions.  The doctor states the patient is totally dependent for activities of daily living (ADLs) and instrumental activities of daily living (IADLs).  An appeal statement by email states the patient's health is declining.  She was hospitalized after fainting. It states the patient is deaf and not yet received hearing aids.  As a result, communication by phone is limited.

Yes, the proposed treatment is medically necessary.

Medically necessary services are those which are:
safe 
effective
generally accepted national standard of medical practice 
not provided primarily for convenience of the patient or the practitioner 
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.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient was approved for 49 personal care aide (PCA) hours per week based on an assessment performed.  The patient lives alone and is appealing for additional evening support.  The assessment shows the patient needs assistance with meal preparation, housework, shopping, managing finances, phone use, bathing, dressing, managing medications, locomotion, toileting, personal hygiene and eating.  Since this assessment, the patient was hospitalized twice.  An appeal letter from her provider states the patient is totally dependent with activities of daily living (ADLs) and instrumental activities of daily living (IADLs).  An appeal letter from her daughter notes that the patient's condition is declining.  The patient is hard of hearing and needs more assistance with medication management.  Based on the provider's statement, this patient's functional status has declined to now being totally dependent.  The currently approved 49 personal care aide (PCA) hours per week are insufficient to meet this functional status.  The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient based on information available at time of the assessment.  In addition, based on information since that time, the requested 63 hours are appropriate for this patient.