Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Endocrine/Metabolic/Nutritional/Diabetes
Treatment:  Home Health Care/increase in personal care services from 28 hours to 49 hours per week 
The health plan denied the requested increase in personal care services from 28 hours to 49 hours per week as not medically necessary. The health plan's determination is overturned.

The patient is a male with a past medical history of diabetes mellitus (DM) Type 2, hyperlipidemia, hypertension, asthma, allergic rhinitis, and vitamin D deficiency who had been assigned personal care assistant (PCA) services 28 hours/week. There was a request to increase PCA services and the patient underwent and assessment assessing the patient at total assistance with task of transportation and maximum assistance with task of shopping. With tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, meal preparation, ordinary housework, dressing upper/lower body, walking, transfer toilet, and toilet use, the patient was assessed at limited assistance, while set up with the task of phone use. The patient was assessed at independent with the task of locomotion, bed mobility, and eating. Notes from the assessment stated the patient lived with her spouse. The insurer sent initial adverse determination denial notice denying request to increase PCA services stating the patient had recently enrolled into their plan and the most recent assessment had been done with no change in the patient's daily activities which required additional hours and there was no change in social circumstances. In addition, the plan denial stated safety monitoring is part of the total personal care service hours for personal care received. The patient's primary care physician (or provider) (PCP) sent a letter stating the patient's diagnoses and the patient was in need of more extended hours for home care assistance with activities of daily living. The patient's spinal surgeon provided a letter confirming the patient's office visit. The patient's ophthalmologist sent a letter stating the patient's ophthalmologic diagnoses with plan for follow up in 6 months. The patient's orthopedist provided a letter noting the patient had been seen in the office for follow up of adhesive capsulitis.
At issue is the medical necessity for the requested health service/treatment of increase in personal care services from 28 hours to 49 hours per week.

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

Yes. There is documentation from the patient's PCP of a need for increased PCA services. The patient requires at least limited assistance with walking, transfer toilet, and toilet use and therefore, has unpredictable and unscheduled care needs that span a continuum of time. The patient requires PCA assistance outside of the time he has informal help. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 49 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 his own home.