Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus. 
Treatment: Home Health Care. 

The health plan denied the request for an increase in Personal Care Assistance (PCA) hours. 

The health plan's determination is overturned. 

The patient is a female with past medical history of diabetes mellitus type 2, hyperlipidemia, gastroesophageal reflux disease (GERD), urinary incontinence, cervical radiculopathy, low back pain, hypothyroidism, lumbosacral spondylolisthesis, osteoarthritis with bilateral shoulder pain, spondylosis, osteoarthritis with bilateral knee pain, unsteady gait, and asthma who had been assigned 4 hours/day, 7 days/week to total 28 hours/week based on an assessment tool performed. At this assessment, the patient was assessed at total assistance with task of ordinary housework while maximal assistance with tasks of meal preparation, managing medication, and shopping. With tasks of stairs, transportation, bathing, dressing upper/lower body, walking, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of managing finances, personal hygiene, locomotion, transfer toilet, and bed mobility. The patient was assessed as set up only for phone use and independent with eating. There was a request to increase CDPAP (Consumer Directed Personal Assistance Program) services and the patient had a telephonic assessment tool performed assessing the patient at total assistance with task of ordinary housework while maximal assistance with task of meal preparation, managing medication, and shopping. The patient was assessed at extensive assistance with task of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use while limited assistance with tasks of managing finances, walking, locomotion, and bed mobility. The patient was assessed at set up only for phone use and independent with the task of eating. The assessment noted the patient to live alone, have increased pain related to arthritis, and needed to eat soft foods. The insurer sent final adverse determination denial notice stating increase in CDPAP services was not medically necessary and did not meet criteria. The denial notice also stated that based on a recent assessment, the patient's personal care needs can continue to be met safely with the current CDPAP services at 4 hours/day, 7 days/week to total 28 hours/week. The patient's primary care physician (PCP) provided a letter stating the patient needs additional home care hours due to worsened medical conditions. The patient's PCP provided another letter again stating the need for additional home care hours due to her worsening medical conditions. The patient appealed the denial decision. 

At issue is the medical necessity of the requested increase in PCA hours. 

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

Yes, the patient has chronic medical conditions of osteoarthritis of the shoulders, knees, lumbar, and cervical spine with worsening functional status as documented by her primary care provider. The patient's PCP documented the need to increase CDPAP services in both letters that he provided. The patient had a telephonic assessment which underestimated her assistance needs for stairs, walking, and locomotion. The patient has the need for assistance with transfer toilet and toilet use both of which are unpredictable and unscheduled needs. The patient does have two informal helpers and would need to have assistance during the hours that she does not have informal helper. The increase in CDPAP hours is not solely for safety and supervision but to assist the patient with safe completion of her activities of daily living (ADLs)/instrumental activities of daily living (IADLs). 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.