Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Liver Disease, Below the Knee Amputation 
Treatment: Personal Care Aide services, from 33 hours per week (5 days x 5 hours and 2 days x 4 hours, total 33 hours per week) 

The insurer denied the Personal Care Aide services, from 33 hours per week (5 days x 5 hours and 2 days x 4 hours, total 33 hours per week). The denial was overturned. 

This is a female patient with a history of cirrhosis of liver/hepatic failure/portal hypertension, esophageal varices, gastroesophageal reflux disease (GERD), hypertension, hyperlipidemia, diabetes mellitus type 2, anemia, MALT lymphoma, vertigo, s/p right below knee amputation, dizziness, osteoporosis, depression, rotator cuff tear right shoulder, bursitis right shoulder, cervical radiculopathy, hearing loss, constipation, pruritis, epistaxis, insomnia. It was reported that the patient has increasing trouble with everyday tasks. She currently has homecare services 30 hours per week.  The physician recommended to reinstate the patient's previous hours (33 hours per week) at minimum, as she is living alone and needs help with all ADLs. 

The patient has several medical problems that could have significant impact on her functional ability. The patient has cirrhosis/hepatic failure due to chronic hepatitis C.  She also has MALT lymphoma (stage and status of disease not known from available records). These conditions cause various symptoms; and both cause fatigue which may at least partly contribute to patient's limited endurance for walking (as per UAS and daughter's letter, patient uses wheelchair often). She has osteoarthritis, and physician notes indicate lower back pain. The physician's records also include substantial upper extremity problems, including history of rotator cuff tear right shoulder with decreased range of motion and right shoulder pain. The patient also has cervical radiculopathy which can cause pain and weakness of upper extremity. These symptoms and limitation of movement of upper extremities can affect many daily activities including most household tasks, and several ADLs, e.g. bathing, dressing, toilet use (UAS reports assistance is needed for these ADLs).  =The UAS reported no recent pain, but it appears the patient has intermittent pain, as the UAS and the physician's note indicate several prn pain medications (UAS: Tylenol, Bengay patch; physician's note: motrin). 

The patient has a right below the knee amputation (BKA) and she uses a prosthetic and walker to ambulate. At this point in her life, with other medical conditions affecting her endurance and mobility, it may be more difficult to walk with the prosthetic. In the UAS the patient's gait is reported as slow (timed 4 meter walk, 22 sec) and unsteady (noted as daily in previous 3 days). The patient also needs assistance with transfers (difficulty moving to standing position unassisted; when aide is present she assists the patient with transfers). The case note from mid-2020 indicates primary focus for POC is fall risk. The patient has difficulty with mobility (including walking and transfers) which increases her risk for falls. 

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

The carrier's denial of Personal Care Aide services, from 33 hours per week (5 days x 5 hours and 2 days x 4 hours, total 33 hours per week) to 30 hours per week (5 days x 4 hours and 2 days x 5 hours, total of 30 hours per week) is overturned. The medical necessity is substantiated.