Appeal type: Medical necessity
Decision: Overturned

Respiratory System/Breathing Problem
Home Health Care

Diagnosis: Respiratory System/Idiopathic Pulmonary Arterial Hypertension
Treatment: Home Health Care
The health plan denied the requested Consumer Directed Personal Assistance Services. The health plan's determination has been overturned.

The patient is a female with a past medical history of idiopathic pulmonary arterial hypertension treated with three medications, one of which is administered through a pump. There was a request for personal care assistance/consumer directed personal assistance services (PCA / CDPAS) by her pulmonologist with a M11Q (medical request for home care) form indicating the patient has increased fatigue, decreased activity tolerance, and dyspnea on exertion due to her medical condition. The patient had a universal assessment tool performed over the phone assessing the patient at extensive assistance for ordinary housework, shopping, and transportation while limited assistance with tasks of meal preparation, stairs, bathing, and dressing the lower body. The patient was assessed at set up only with a task of equipment management and independent with tasks of managing finances, managing medication, phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The assessment noted the patient lived with her son and daughter. It noted the children's father helped with grocery shopping. The patient needs assistance with her medication pump change every 6 weeks. The patient was interested in CDPAS, as her mother could come from Connecticut to New York on service days to assist the patient. The HELPS (assessment tool) indicated the patient needed 7.91 hours of assistance.
The insurer sent final adverse determination denial notice denying coverage for PCA/CDPAS services stating they were not medically necessary. The notice stated the patient is able to perform activities such as personal hygiene, toileting, and can walk on her own, therefore does not require CDPAS. The denial further stated "the assessment shows that you live with your children.  Children's father is supportive and assists you as needed". The patient appealed the adverse decision and documented she needs daily assistance to shower, clean, and someone to accompany her to do groceries. It stated also that she gets out of breath fast and daily activities are a struggle.

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

Yes. The patient has a medical diagnosis causing her to be short of breath with exertion, have baseline fatigue with the need for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The assessment tool performed documented the patient to need extensive assistance with tasks of ordinary housework, shopping and transportation and limited assistance with tasks of meal preparation, stairs, bathing, and dressing the lower body. The plan assumes the patient has adequate support from her children and her children's father. The patient does not have an informal helper and has stand-alone ADL and IADL tasks that require assistance based on tasking tool. 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. The patient's medical provider recommended and ordered PCA/CDPAS services based on her underlying medical illness and need for assistance with ADL's and IADL's. Medical necessity is further defined as medical care and services that are necessary to prevent, diagnose, correct, or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity or threaten some significant handicap.