Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, falls, chronic fatigue, cognitive decline, and dyspnea.
Treatment: Consumer Directed Personal Aide Services 56 hours a week.
The insurer denied coverage for Consumer Directed Personal Aide Services 56 hours a week. The denial is overturned.

This case involves an elderly female with a history of osteoporosis, falls, chronic fatigue, cognitive decline, and dyspnea was being recommended for a personal care aide 56 hours a week. Records indicated that following a recent assessment the patient required assistance with bathing, dressing, and using the bathroom. She needed help with brushing her teeth, washing her face, and walking. In addition, she required supervision with managing medications and was able to eat independently once things are set up. She was totally dependent on others to clean her house and do laundry. The physician stated that an increase in personal care services was medically necessary in order to meet all her personal care needs. She required assistance daily for 10 hours given that she is homebound and considered a danger to herself, due to early signs of dementia and history of falling. This is characterized by problems with memory, language/word retrieval, and judgment. The patient is not oriented to time or place and requires total assistance with ADLs (activities of daily living) to include bathing, dressing, toileting, transferring from bed to wheelchair, using wheelchair, meal preparation, and prompting her to take her up report medications. The physician stated that the patient lives alone with no formal supports to provide her with assistance to meet her care needs on a regular basis. This review pertains to the denial of coverage for consumer direct, 1 client personal care aide 56 hours/week. The healthcare plan did not act reasonably and with some medical judgment and in the best interest of the patient.

Current medical literature notes that personal care services are available to those individuals who require and may benefit from assistance with activities of daily living and independent activities of daily living rather than receiving treatment and/or care in a nursing facility or assisted living. The information provided for the review indicated that the patient was previously authorized 40 hours a week personal care aide with a current request for 56 hours a week. The information provided for the review stated that the patient lives alone, was homebound, and had cognitive decline over the past year. She was a fall risk, required assistance with all activities of daily living/independent activities of daily living, and was a danger to herself. The treating physician submitted information regarding the extent of the patient's condition and recommended 56 hours, which would allow for assistance 8 hours a day, 7 days/week. Given the provided information, it was determined that the request was reasonable based upon the extent of the patient's physical and mental status. As such, the request for Consumer Direct, 1 client Personal Care Aide 56 hours/week is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Consumer Direct, 1 client Personal Care Aide 56 hours/week services is substantiated.