Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 40 hours per week. 
The insurer denied Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 40 hours per week. 
The determination is overturned.

The patient has a past medical history of hypertension, anxiety, depression, mild intellectual disability, thyroid nodule, scoliosis, osteoarthritis, abnormalities of gait and mobility, and memory disorder who had been assigned personal care assistant (PCA) hours 20 hours/week. The patient had an assessment tool performed over the telephone assessing her at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, stairs, and transportation. The patient was assessed at limited assistance with tasks of bathing and dressing upper/lower body while independent with tasks of personal hygiene, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The notes from the assessment stated the patient lived with her daughter and her daughter wanted to be a PCA through the Consumer Directed Personal Assistance Program (CDPAP).

The patient's primary care physician (PCP) provided a letter stating the patient's medical diagnoses and that her medical conditions impair her ability to function independently with every day necessities. The letter also stated the patient's health is declining and she needs assistance to prevent physical injuries due to falls and the patient has limited ambulation. Lastly, the PCP letter recommended the patient have 40 hours to be assisted with basic necessities.

The patient underwent another assessment over the telephone assessing her at maximum assistance with the tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing finances, phone use, stairs, shopping, transportation, bathing, and dressing lower body. The patient was assessed at limited assistance with the tasks of personal hygiene and dressing upper body while independent with tasks of walking, locomotion, transfer toilet, toilet use, bed mobility, and eating.

The insurer sent a final adverse determination denial notice denying the request to increase CDPAS to 40 hours/week. The notice stated the request was not medically necessary and did not meet criteria. The denial further stated the patient had no loss of motor function, no changes with most of her physical functioning since prior assessment, had memory that was "ok", had no reported bladder or bowel incontinence, and hours beyond those approved would be for safety monitoring which is not a covered benefit. The patient's health care advocate provided a letter requesting external appeal of denial of request to increase CDPAS hours from 20 hours/week to 40 hours/week. The advocate's letter also stated the patient had declining functional mobility and recent cataract surgery  which had impacted her ability to ambulate and transfer independently. In addition, the advocate noted the patient's daughter had stated the patient's osteoarthritis and scoliosis has progressed and she has experienced increased difficulty with any type of weight bearing transfer. The letter also stated the patient requires an increase in personal care service hours as the patient requires greater assistance when trying to ambulate or stand from a seated position. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 40 hours per week. 

The services are medically necessary. The patient has documented chronic progressive medical diagnoses of osteoarthritis and memory loss with documented worsening physical and mental functioning. The patient did have a change in assistance needs with increased need with the tasks of phone use, bathing, personal hygiene, and dressing lower body. The patient's primary care physician (PCP) noted that the patient has "limited mobility and is dependent on others for everyday living necessities". There is documentation of worsening ability to walk, transfer, and provide incontinence cares following cataract surgery. The increase in CDPAS hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs)/ Instrumental activities of daily living (IADL). The patient's increase in assistance needs cannot be met solely with medical supplies and adaptive equipment. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS to total 40 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.