Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 

The insurer denied an increase in Personal Care Assistance service. 
The denial was overturned. 

The patient is a female with a past medical history of hypertension, coronary artery disease, chronic kidney disease, diabetes mellitus type 2 with neuropathy, idiopathic peripheral autonomic neuropathy, urinary incontinence, wheelchair dependence, obesity, osteoarthritis, and mitral insufficiency. She had been approved personal care assistance (PCA) services 7 hours/day times (x) 3 days/week, 6 hours/day x 2 days/week, and 3 hours/day x 2 days/week, all to total 39 hours/week. 

There was a request to increase PCA services and the patient underwent a telephonic assessment tool assessing the patient at maximum assistance with tasks of ordinary housework and shopping while extensive assistance with tasks of meal preparation, managing medication, stairs, transportation, equipment management, bathing, dressing upper/lower body, transfer to toilet, and toilet use. The notes from the assessment stated the patient had fallen 15 times in the last 3 months and one time fell off the commode when she was alone. 

The insurer sent a final adverse determination denial notice stating the request to increase PCA hours was not medically necessary. The patient's primary care physician (PCP) provided a letter stating the patient's medical diagnoses, her medications, and that she is wheelchair dependent, has weakness of her lower extremities, can barely walk, and has poor exercise tolerance. The PCP letter further stated the patient has osteoarthritis with a right knee replacement in the past. 

At issue is the medical necessity of Personal Care Assistance services 12 hours per day, 7 days per week (Monday through Sunday) for a total of 84 hours per week. 
The health plan's determination of medical necessity is overturned in whole. 

Yes, the requested health service/treatment of Personal Care Assistance services 12 hours per day, 7 days per week (Monday through Sunday) for a total of 84 hours per week, is medically necessary for this patient. 

The patient has documented progressive medical illnesses and worsening in her physical functioning with multiple falls. The patient has diabetic neuropathy and idiopathic peripheral autonomic neuropathy which puts her at high risk for falls even with assistive devices. The patient requires at least some assistance with all tasks except bed mobility and eating. The patient needs assistance with walking, locomotion, transfer to the toilet, and toilet use, all of which are activities utilized for unpredictable and unscheduled care needs such as toileting and incontinence care. The insurer did not document a plan to manage these unscheduled and unpredictable care needs. The patient requires assistance with activities of daily living (ADL)s /Instrumental activities of daily living (IADL)s outside of the hours she has informal help. 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, PCA services 12 hours/day, 7days/week, to total 84 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 Personal Care Assistance services 12 hours per day, 7 days per week (Monday through Sunday) for a total of 84 hours per week are medically necessary.