Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied increase in Consumer Directed Personal Assistance Services to 63 hours per week.
The denial is overturned.

The patient is a female with past medical history of multiple system atrophy (MSA), orthostatic hypotension, supine hypertension, insomnia, urinary retention, urinary incontinence, constipation, anxiety, depression, gait instability, and syncope who had been assigned 6 hours/day, 5 days/week and 5 hours/day, 1 day/week of Consumer Directed Personal Assistance Services (CDPAS) services and 5 hours/day, 1 day/week of personal care worker (PCW) services to total 40 hours/week of services based on telephonic assessment tool performed. The patient was assessed at total assistance with task of stairs, while maximum assistance with tasks of meal preparation, ordinary housework, and shopping. The patient was assessed at extensive assistance with tasks of managing finances, transportation, equipment management, bathing, personal hygiene, and dressing upper/lower body while limited assistance with tasks of managing medication, phone use, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes from the assessment stated that the patient ambulated with wheelchair and scooter or she was wheeled by others.

The subject under review is the medical necessity for an increase in hours. 

The increase to 63 hours per week as requested is medically necessary for this patient. The patient has documented progressive neurodegenerative disorder with worsening physical function and speech. The patient's neurologist has documented medical necessity of increased CDPAS/PCW services. The neurologist last letter noted the patient is not able to transfer independently with the use of assistive device for toileting, is not able to get around her apartment in wheelchair unassisted, is not able to call 911, and requires assistance with catheterization for neurogenic bladder. The patient has unscheduled and unpredictable care needs over a continuum of time. The patient needs at least some assistance with all activities of daily living (ADLs)/Instrumental activities of daily living (IADLs). The patient would need CDPAS/PCW services outside of the time that she has informal help. The increase in CDPAS/PCW services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be solely met with adaptive equipment and medical supplies. The patient's neurologist had noted that the patient has completed physical therapy in the past.
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, CDPAS services 9 hours/day, 4 days/week, and PCW services 9 hours/day, 3 days/week to total 63 hours/week are medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.