Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post traumatic stress disorder (PTSD), constipation, muscle spasms, pain, and urinary incontinence

Treatment: Personal Care Aide 25 hours/week Consumer Directed; 1 Client

The insurer denied coverage for Personal Care Aide 25 hours/week Consumer Directed; 1 Client

The denial is Overturned.

This case involves an adult male regarding a denial of coverage for consumer directed personal care aide 25 hours/week. The assessment conducted noted the patient was independent for cognitive skills in terms of daily decision-making, bathing, personal hygiene, dressing the upper body, toilet use, toilet transfer, eating, walking, and locomotion. The patient required limited assistance for dressing the lower body, shopping and supervision for managing medications. The patient required maximal assistance with meal preparation, and ordinary housework. The diagnoses included constipation, muscle spasms, pain, and urinary incontinence. The assessment noted the patient understands and was able to communicate. The patient had adequate vision with no reported falls but did endorse having an unsteady gait. The patient reported severe pain with his pain not adequately controlled with his therapeutic regimen. The patient did not require an assistive device for walking and had no foot problems. The patient believes that he is capable of improved performance in physical function, although the care professional did not agree. The patient had not driven a vehicle in the last 90 days and had no hospital visits in the last 90 days. The patient received a notice of adverse determination regarding request for approval for 25 hours/week of consumer directed personal care aide.  The patient's plan approved 12.25 hours/week. Following the assessment, it was determined that a full 25 hours/week of services was not medically necessary as the patient's needs could be met with the 12.25 hours/week. The patient was therefore approved for 12.25 hours/week of consumer directed personal care aide services. Missing information provided; the patient did not satisfy the requirements for all the additional hours requested. A letter was submitted stating that the patient had been working in cognitive behavioral and dialectical behavioral therapy, meeting with the physician biweekly via telephone for the sessions. The patient was diagnosed with posttraumatic stress disorder (PTSD) and the physician and patient had been working towards an increased amount of exposure to public places given that these were triggers for the patient's PTSD. With exposure, the patient's negative response to public places was expected to decrease over time. The patient lives in what was described as a "very rural area" and has expressed to the physician that it takes approximately 1 hour each way to go to public places with his support person (his son). The patient's son is only being paid for approximately 12 hours/week and to provide more consistent exposure for the patient to work towards his goals, the recommendation was to increase his personal care services hours to 25/week. 

Personal assistant services (PAS) allow patients to remain in the comfort of their own home to receive care/treatment rather than residing in a skilled nursing facility, long-term acute care, or assisted living. The information provided for the review noted that the patient suffers from posttraumatic stress disorder (PTSD) and was trying to work on improving his condition with exposure therapy, which was difficult to achieve given the area the patient lives in. After a review of the provided documentation, the recommendation is to overturn the prior denial and approve the additional hours. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Personal Care Aide 25 hours/week Consumer Directed; 1 client is substantiated.