Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain without sciatica and osteoarthritis
Treatment: Personal care aide 4 days times (x) 8 hours (hrs)
The insurer denied Personal care aide 4 days times (x) 8 hours (hrs).
The determination is upheld.

The patient is a male with a medical history notable for low back pain without sciatica and osteoarthritis. Personal care aide 4 days times (x) 8 hours (hrs) was requested. The patient's physiatrist provided a letter of support for this appeal. The letter states that the patient has a medical history notable for schizophrenia, prediabetes, blindness, and osteoarthritis. The physician has been managing the patient's low back pain which has recently worsened. The patient has degenerative disc disease and facet arthropathy. His pain prevents him from performing many activities of daily living. Due to his worsening condition, the physician states that 12 hours per week of home health care is insufficient to meet his needs. The physician recommends 32 hours per week to prevent further injury to the low back.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has had declining health and worsening mobility. He recently began ambulating with a cane. He is working with physical therapy. The physician recommends 32 hours per week of home health care. There was no discussion regarding currently unmet personal care needs.
Caseworker notes were provided for review. They described that the patient does require assistance with most Instrumental activities of daily living (IADLs). He walks with a cane for the visually impaired. He is able to ambulate independently without a device.
Physical therapy notes were provided for review. Notes state that the patient performs basic activities of daily living (ADLs) with assistance. He lives alone and ambulates without any assistive device. Goals of physical therapy included being able to ambulate for several blocks with decreased pain, tolerate sitting for prolonged periods, and be able to perform sit to stand transfers with decreased lower back pain.
Assessment results were provided for review. The patient requires maximal assistance for meal preparation, housework. He requires extensive assistance for shopping, stairs, and transportation. For his activities of daily living, he requires limited assistance for bathing. He is otherwise independent or requires supervision only. At issue is the medical necessity of Personal care aide 4 days times (x) 8 hours (hrs).

The requested health service of Personal care aide 4 days x 8 hrs has not been clearly demonstrated to be medically necessary for this patient.
The patient has some functional deficits secondary to mechanical low back pain. These deficits are complicated by vision impairment. He requires assistance primarily with instrumental activities of daily living and some assistance with activities of daily living. The letters and notes provided do not describe any currently unmet personal care needs. The letters state that 12 hours of personal care is insufficient to meet the patient's needs, however he recently was approved for an increase to 23 hours per week. There is no documentation that clearly demonstrates that his personal care needs would not be met at this increased level of 23 hours per week. Therefore, there is insufficient documentation that the requested increase in personal care hours is medically necessary for the patient.