Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epilepsy, Uncontrolled Seizure Disorder
Treatment: Personal Care Services (PCS)
The insurer denied Personal Care Services. 
The health plan's determination is upheld.

The patient is a female with a medical history notable for uncontrolled seizure disorder, autoimmune encephalitis and deficits secondary to her condition. The patient and her care team requested personal care services (consumer directed) to assist with her care.

A letter of support for this appeal was provided by the treating physician. The letter reviews the patient's medical course. She was initially admitted to the hospital with a new onset of seizure disorder, and subsequently diagnosed with autoimmune encephalitis, new-onset refractory status epilepticus febrile infection-related epilepsy syndrome (NORSE FIRES). She started monthly intravenous immunoglobulin (IVIG) infusions and then had a plasma exchange. She was stabilized and discharged to rehab and was eventually to discharge home. Because of these events, she suffers from some cognitive issues which affect her ability to care for herself. The physician is requesting a home health aide "to assist her during the day and to monitor her when she has a seizure requiring emergency medications."
A letter of support for this appeal was provided by the pediatric neurologist who is treating the patient. The letter states that she requires assistance for activities of daily living such as bathing, meal preparation, and housework. She has memory loss and continues to have seizures. The letter states that she was receiving IVIG treatments in the hospital and suffered respiratory failure and cardiac arrest which have affected her functional status.
An office visit note from the treating physician was provided for review. The note summarized the patient's course throughout the previous two years, from her initial presentation and workup through her more complicated admission with the cardiac arrest. At the time of the visit, the patient was ordered routine age-appropriate screenings and immunizations and instructed to follow up in 1 year. Cognitive problems were noted and the patient was referred for neuropsychiatric testing. She was not noted to have any neurologic or musculoskeletal defects that would impact functional ability.
The patient's medical records, including discharge summaries and diagnostic testing such as electroencephalogram (EEG), were provided and reviewed in detail.
A Community and State New York long-term services and supports (LTSS) Face to Face assessment was completed and was available for review. The review states that the patient was alert and oriented with recall intact. She is continent of urine and stool. She was able to get up from a seated position and perform activities of daily living (ADL's) without assistance, including dressing, bathing, meal preparation, and medication management. The review notes that she is "independent with all aspects of her personal care."

The request from the patient's family to have patient care services to administer medication in the event of a seizure is not typical use of patient care assistance, as safety monitoring in the event of a seizure is not a covered service. Personal care services typically cover deficits in functional status to assist with ADL's and Instrumental activities of daily living (IADL's). Per the documentation the patient does not appear to have any functional deficits. The letter from the treating neurologist does attest to need for assistance with ADL's, but the primary care physician letter and notes do not have any mention of specific deficits. She has had a history of some challenges in the setting of the prior cardiac arrest and subsequent recovery, but at this time there is no demonstrated medical necessity for ongoing need of personal care assistance.