Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Postural orthostatic tachycardia syndrome (POTS)
Treatment: Personal Care Services
The insurer denied: Personal Care Services
The denial is: Overturned

This patient has a past medical history of postural orthostatic tachycardia syndrome (POTS), asthma, temporomandibular joint (TMJ) dysfunction, fibromyalgia, depression, migraines, and chronic pain who requested Personal Care Assistance (PCA) services and underwent a telephonic assessment assessing the patient at total assistance with task of shopping, limited assistance with tasks of meal preparation and ordinary housework while independent with all other tasks. Notes from the assessment stated the patient had 3 falls in the last 3 months. In addition, the notes from the assessment stated the patient's friend was providing help with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) 18 hours in the last 3 days. The patient's provider completed medical review and practitioner's order form noting the patient's medical diagnoses, noting the patient's medical condition was stable, and stating the patient used a cane indoors and walker outdoors. 

The patient's primary care physician (PCP) provided a letter stating the patient had fibromyalgia, autonomic dysfunction, weakness, gait instability, and walked with a cane or Rollator and had fallen recently due to these issues and needed emergency room visits. The letter stated the patient's autonomic dysfunction also caused issues with lightheadedness, passing out, and fatigue and sometimes symptoms start quickly, and the patient is unable to compensate fast enough and potential injuries may ensue. 

The health plan's determination is overturned. 

The requested Personal Care Services are medically necessary for this patient. There is documentation from the patient and the patient's medical provider of assistance needs with cooking, showering, transportation, walking, and ordinary housework. The patient has a medical condition which causes severe hypotension with episodes of weakness, presyncope, and syncope at unpredictable times. The denial from the plan incorrectly stated the patient did not require an assistive device to walk. The assessment underestimated the patient's assistance needs with activities of daily living. The patient was noted to be independent with all ADLs which was not the case as per the patient's medical provider and the patient. The plan's assessment noted the patient required assistance with IADLs and ADLs 18 hours over the last 3 days. In addition, the plan's assessment noted the patient had 3 falls in the last 3 months. The requested PCA service hours cannot be met with adaptive equipment and medical supplies alone. The requested PCA service hours are to assist the patient with ADLs and IADLs and are not solely for safety and supervision. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 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 their own home.