Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbidly obese with polyarthritis and chronic pain

Treatment: 116 hours/week; consumer directed; 1 client personal care aide

The insurer denied coverage for 116 hours/week; consumer directed; 1 client personal care aide

The denial is upheld 


The patient is an adult seeking coverage for 116 hours/week of consumer directed 1 client personal care aide.  The patient has Hepatitis C, chronic obstructive pulmonary disease, congestive heart failure, hypertension, gastroesophageal reflux disease, anxiety, depression, obesity, asthma, chronic pain, cirrhosis, and weakness.

It was noted that the patient was requesting an increase in personal assistance care hours.  The patient's goals included getting more hours to help their heart and lungs and to remain safe in the community setting with assistance.  The patient was independent with cognitive skills for daily decision making. The patient was frequently incontinent of bladder and infrequently incontinent of bowel.  The patient reported severe constant pain that was not adequately controlled by therapeutic regimen.  The patient reported that they had 10 falls total in 3 months. She reported that she fell recently when on the way to the bathroom.  The patient was not utilizing an assistive device at the time.  The patient was observed ambulating with an unsteady gait.  The patient reported difficulty sleeping at night secondary to pain and worrying about health conditions.  The patient utilized Dilaudid twice a day for pain management.

The provider stated that the patient was morbidly obese with polyarthritis and chronic pain.  The patient had decreased mobility, frequent falls, and generalized deconditioning.  The patient required assistance with dressing, bathing, meal preparation, laundry, cleaning the house, and grocery shopping.

The patient complained of chest pain, shortness of breath, and palpitations in the setting of coronary arthrosclerosis, carotid artery disease, hypertension, hyperlipidemia, aortic valve disease, mitral valve disease, and obstructive sleep apnea.  The patient had multiple cardiac symptoms in the setting of known risk factors and known cardiac disease.  The patient had chronic shortness of breath secondary to lung disease, but this was getting progressively worse and happened when walking across the room.  The patient was a current smoker but had decreased smoking from 2 packs a day to 2 cigarettes a day.  

Per the cited references, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support.  The services must be essential to the maintenance of the patient's health and safety in their home, be ordered by physician or nurse practitioner, and be based on an assessment of the patient's needs for the service in accordance with guidelines.  Allotment of time separate and apart from personal care tasks authorized is not required for safety monitoring.  However, there is a clear and legitimate distinction between safety monitoring as a nonrequired stand-alone function while no personal care services are being provided and the appropriate level of safety monitoring while the patient is receiving assistance with personal care services such as transferring, toileting, or walking.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 116 hours/week; consumer directed; 1 client personal care aide services is not substantiated.