Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebral palsy, cauda equina syndrome, Schwannoma of spinal cord status post resection, and cognitive impairment 

Treatment: continuation of 36 hours per week of personal care services for the dates of service specified.

 The insurer denied coverage for continuation of 36 hours per week of personal care services for the dates of service specified. The denial was reversed.

This patient is a male patient with past medical history: cerebral palsy, cauda equina syndrome, Schwannoma of spinal cord status post resection, and cognitive impairment. Exam noted that the patient was mostly nonverbal; difficult to understand speech.  The physician completed M11Q so the patient can get increase of home care hours (note: this M11Q was not provided for review).  The physician noted hours were reduced from 36 to 9 which are inadequate as elderly guardian cannot care for the patient independently.

Neurosurgery office visit note includes the following: Patient has worsening balance and gait instability.  MRI of lumbar spine did not show residual tumor, and so it is necessary to look for other sources contributing to his gait instability.  MRI of thoracic and cervical spine was requested.

Neurosurgery office visit note includes the following: Patient's gait and hand dexterity continues to worsen.  Patient needs CT cervical spine to determine if patient has cervical myelopathy. 

Office visit note includes the following: Patient was previously seen for severe gait abnormality and was referred to physical therapy (PT). Exam: musculoskeletal: bilateral ankle contractures, bilateral knee valgus deformities, bilateral wrist extension to midline only, 60 degree shoulder abduction; neuro: increased tone bilateral upper and lower extremities, limited verbal use, follows simple commands, cooperative.  Recommend school based PT program.

The most recent UAS indicates the patient needs assistance for all IADLs (extensive to maximal assistance; or total dependence).  Regarding ADLs, he needs extensive assistance with bathing, personal hygiene, dressing and toilet use; limited assistance with eating; independent with setup help for walking, locomotion and transfer toilet.

The number of PCA hours cannot be properly determined until addressing the issue of caregiver assistance.  If PCA hours are reduced to 9 hours per week, all other assistance needed by the patient becomes the responsibility of an identified relative (who is the only informal caregiver, as per UAS).  The risk is greater when the caregiver is older and/or has health problems.  This can result in harm not only to the caregiver, but to the person receiving care; as the caregiver may not always be able to provide safe and effective assistance if the caregiver's health is impaired; especially if the care recipient requires strenuous, weight-bearing assistance (as this patient does).  This places the health and safety of the caregiver and care recipient at risk.

Personal care services 36 hours per week are medically necessary.

Based on the above, the medical necessity for continuation of 36 hours per week of personal care services for the dates of service specified is substantiated.  The insurer's denial is reversed.