Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, heart failure, ASHD/CAD, diabetes mellitus type 2,

Treatment: Personal Care Assistance, Level II, from 22 hours per week to 49 hours per week

The insurer denied coverage for Personal Care Assistance, Level II, from 22 hours per week to 49 hours per week. The denial is reversed. 

This patient is a female has an extensive medical history associated with functional impairment and needs assistance with various daily activities. The 4th quarter 2019 UAS indicates patient was receiving PCA services 49 hours per week (7 hours per day, 7 days per week). The UAS was noted as a first assessment, so it appears the patient may have changed insurance plans. The appeal decision notice indicates the insurer approved PCA services 22 hours per week. It appears the insurer decreased the patient's PCA hours from 49 to 22 hours per week following the UAS.  The patient requested PCA services 49 hours per week, which was denied.  An external appeal was requested.

The patient's functional status (as noted in the UAS) indicates need for substantial assistance with household related tasks (meal preparation, housework) and mobility on stairs and outside the home. For ADLs, she needs extensive or limited assistance for most self-care activities (bathing, hygiene, dressing, toileting), and independent with setup help for walking, eating and bed mobility. The patient has no reported cognitive deficits. She has h/o depression and anxiety with intermittent symptoms; report from the UAS indicated patient's mood was stable at the time of assessment.

The UAS indicated the patient can walk without assistance. The patient may be able to walk unassisted; however, it is not necessarily safe. The patient has difficulty with mobility due to impaired balance, s/p transmetatarsal amputation, sensory and pain symptoms (neuropathy), intermittent dyspnea (heart failure/asthma), and intermittent symptoms due to recurrent hypoglycemia. It appears some level of assistance would be useful to help the patient maintain stability and safety during ambulation.

The patient's multiple medical conditions have a cumulative adverse effect on her functional capacity. The patient has various causes of physical stress with daily activities due to pain, restricted movement of upper and lower extremities, impaired sensation, dyspnea, fatigue. Being alone and having difficulty with basic activities can also increase emotional stress (depression, anxiety). The combined effect of these symptoms results in significant burden for performing routine daily tasks. In addition, the physician reports that patient has frequent hypoglycemia, which can cause symptoms that further impair her mobility (e.g. dizziness), and can have critical consequences if she has a severe episode. 

Based on the information provided for review, the patient has significant functional impairment and limited ability to perform daily activities due to various chronic medical conditions. It is medically necessary for the patient to have caregiver assistance with most IADLs and ADLs, including ADLs that occur throughout the day (i.e. toileting, transfers, walking). In the absence of informal caregivers who can provide assistance, then personal care services are indicated to provide the necessary assistance. The patient was previously receiving PCA services 7 hours per day, 7 days per week. The patient's medical condition and functional impairments do not appear to support a decrease in PCA services.

Increase of Personal Care Assistance Services Level II, from 22 hours per week to 49 hours per week is medically necessary.

The health plan did not act reasonably with sound medical judgement in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Assistance, Level II, from 22 hours per week to 49 hours per week is substantiated.  The insurer's denial is reversed