Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Static Encephalopathy

Treatment: Coverage of 40 hours per week of Personal Care Assistance (PCA) Services

The insurer denied coverage for coverage of 40 hours per week of Personal Care Assistance (PCA) Services.

The denial is overturned.

This case involves a patient with a subject of review for the coverage of 40 hours per week of Personal Care Assistance (PCA) Services.

According to the Comprehensive Community Health Assessment Report, the patient resides with their spouse in a 1-bedroom apartment. The patient is alert and oriented x2, able to recall their date of birth (DOB) and address, but the patient's spouse makes decisions and directs caregivers. The member cannot activate personal emergency response system (PERS). The patient is often understood and has difficulty finding words, and hearing and vision are adequate. The patient spends less than 1 hour alone during the day. 

A Mini-Mental State Examination was done and the member was unable to participate due to impaired cognition.

An Initial Adverse Determination Denial Notice was submitted for the request for 40 hours per week of Personal Care Assistance Services. The plan approval stayed at 23 hours per week of Personal Care Assistance Services.

The Final Adverse Determination Denial Notice was sent for the request of the provider for 40 hours per week of Personal Case Assistance Services. The plan approval stays at 23 hours per week of Personal Case Assistance Services. 

A Medical request for Home Care was submitted for the diagnosis of Mental Disorder, Type 2 Diabetes, Unspecific Convulsions, Hypertension, Restless Leg Syndrome and Encounter Screening for Malignant Neoplasm of Prostate. 

A letter of medical necessity was submitted and the provider stated that the patient suffers from a Psychiatric disorder because of a diabetic coma. The patient cannot be left alone and needs constant supervision and care.

A letter of medical necessity was submitted for a patient with a diagnosis of Anxiety, Depression, Sensorineural Hearing Loss, Diabetes and Memory Loss. The patient has been experiencing exacerbation of their symptoms which include gait and balance issues, involuntary movements, echolalia, fecal/urinary incontinence, and poor insight. For these reasons, the provider recommending homecare service hours be increased to 40 hours per week. 

According to a letter of medical necessity submitted, the patient has been living with brain damage for 11 years. The patient was diagnosed with severe Static Encephalopathy. The patient's mental and physical condition have significantly declined since. The patient needs assistance with all activities of daily living (ADLs), including transferring. The patient also has issues with gait and balance, involuntary movements, and fecal/urinary incontinence. 

The provider is requesting 40 hours per week of Personal Case Assistance Services to a patient with a medical history of Diabetic coma with brain damage, diabetes mellitus (DM), hypertension (HTN), Depression, Anxiety, Dementia. The nurse observed that the member ambulates with slow gait and uses furniture for support. The member also requires assistance with instrumental activities of daily living (IADLs) such as shopping, cooking, home maintenance and laundry. Current medication includes clonazepam, divalproex sodium, enalapril, gabapentin, glipizide, Ingressa, metformin and trazodone. Supervision with bed mobility, eating, and the patient walks with the use of assistive device.

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 assistance (PCA) services 40 hours per week is substantiated.