Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Consumer Directed Personal Assistance Program-8 hours a day, 7 days a week; 56 hours a week total. The denial was overturned. 

The patient is a female with a past medical history of type 2 diabetes, hypertension, hyperlipidemia, sleep disorder, right eye blindness, depression, and vertigo, who had been assigned personal care services. The patient underwent an assessment. She lives at home with her son and daughter-in-law. Regarding her functional status, she is cognition modified independent with mild memory problems, she is able to communicate and understand others. She has minimal vision difficulty, with no hearing difficulty. She requires assistance with Instrumental Activities of Daily Living assistance (IADLs) as follows: total dependence with meal prep, total dependence with housework; maximal assistance with managing medications and total dependence with finances, extensive assistance with stairs, and total dependence for shopping and extensive assistance for transportation.
She requires assistance with Activities of Daily Living (ADL) assistance as follows: extensive assistance with bathing, extensive assistance needed for personal hygiene, dressing the upper body, dressing the lower body, locomotion and walking, toileting transfers, toilet use, with bed mobility and eating. She uses a walker for ambulation. She is occasionally incontinent with bladder and frequently continent with bowel. ADL status in the last 90 days is unchanged, however, self-sufficiency has deteriorated. She had one fall, with a reported fall with an attempt to go to the bathroom and felt dizzy and unsteady. She has diminished energy and is unable to complete day-to-day activities. She has no pressure ulcers. Per assessment, she required about 45 hours of personal assistance services.
The patient's primary care physician wrote a letter stating her medical conditions which included vertigo which can cause her to fall and requesting an increase in home care services. Per a letter from the patient's daughter, she is no longer able to perform any tasks, requires constant care and supervision, and suffers from poor vision, amnesia, depression, and vertigo.
At issue is the medical necessity of Consumer Directed Personal Assistance Program-8 hours a day, 7 days a week; 56 hours a week total.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Consumer Directed Personal Assistance Program-8 hours a day, 7 days a week; 56 hours a week total, is medically necessary for this patient.
Based on assessments, the patient has a decrease in self-sufficiency requiring assistance with all tasks and is at risk of falls from dizziness and vertigo. The assessment tool noted that the patient required extensive assistance with basically all ADLs and IADLs. In addition, the letter from the patient's primary care physician indicates risk of falls with vertigo and requests increased home care. Taking into account the clinical standards, all information provided regarding the patient, the primary physician's recommendations, and the applicable and generally accepted practice guidelines, personal care assistance (PCA) services 8 hours/day, 7 days/week, to total 56 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Therefore, the requested health service/treatment of Consumer Directed Personal Assistance Program-8 hours a day, 7 days a week; 56 hours a week total, is medically necessary.