Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairments; osteoarthritis; fibromyalgia

Treatment: Personal Care Assistance services from 11 to 25 hours per week

The insurer has denied coverage for Personal Care Assistance services from 11 to 25 hours per week. The denial was reversed.

This female patient has several medical conditions, including osteoarthritis and fibromyalgia, which are primarily associated with the patient's functional impairments.  The most restrictive symptom identified in the UAS is pain.  The Care Management supplement indicates the pain is in the back and upper and lower extremities.  Also noted is numbness in the hands and feet, which is associated with fibromyalgia.  The patient is taking multiple medications for pain, including nabumetone, Tylenol, gabapentin, baclofen and tramadol. It does not appear that the pain is consistently well controlled as the description in the UAS notes pain is constant, highest intensity is severe, with acute flare-ups.  The patient has unsteady gait, difficulty moving to a standing position unassisted, and limited time that she can stand or walk.  With pain and numbness in her hands, this also limits her ability to perform tasks that require hand dexterity. The patient also reports fatigue and diminished energy (common symptom of fibromyalgia) which affects her ability to finish daily activities.

The patient's medical conditions are chronic and can be debilitating.  Arthritis and fibromyalgia often have an adverse effect on the ability to perform daily activities.  The patient is taking extensive medications for pain, so it is likely that she and her physicians have been trying to find an optimal regimen, but with limited success.  Some of the medications she is taking have significant side effects (e.g. -nonsteroidal anti-inflammatory drug [NSAID], opioid), and need to be used with caution.  Providing the patient with assistance for a more extended period of the day is one way to decrease the physical stress of movement with all her daily activities.  It is not clear why there is no time allocated for any Activities of Daily Living (ADL) on the weekend.  The son does not assist with ADLs, so the patient has no help with ADLs on Saturday and Sunday with the current allocation of hours (11 hours per week, Monday-Friday as noted in the UAS-ATSP).

It is in the patient's best interest to provide more assistance for ADLs each day of the week.  Additional hours are medically necessary for the same reason the previously approved hours (11 per week) were medically necessary, i.e. the patient's symptoms (pain, numbness, fatigue) restrict the patient's ability to perform basic daily activities.  Her symptoms are not limited to 2 hours per day, and several daily activities occur beyond 2 hours per day; therefore, she needs assistance for a more extended period of the day to improve her ability to function in her home.  

Personal care assistance services are approved for 25 hours per week. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest. 

Based on the above, the medical necessity for personal care assistance services, 25 hours per week is substantiated.  The insurer's denial is reversed.