Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Back pain. 
Treatment: Home Health Services/Personal Care Services (PCS)/Home Personal Care Services 6 hours per week of homemaker services. 

The insurer denied  Personal Care Services (PCS)/Home Personal Care Services 6 hours per week of homemaker services. 

The determination is overturned. 

The patient has a past medical history of morbid obesity, hypertension, diabetes mellitus type 2, back pain with sciatica, chronic pain, depression, obstructive sleep apnea (OSA), and varicose veins whose primary care physician (or provider) (PCP) provided M11Q form requesting home care services stating the patient had chronic back pain and increased dizziness and the patient would benefit from help at home with a home health aide with simple tasks such as cleaning and cooking. This form also stated the patient had continued depression which continued to exacerbate and poor control of his back pain, thus increasing his need for help with instrumental activities of daily living (IADLs).
The patient underwent an assessment tool assessing the patient at limited assistance with tasks of meal preparation, ordinary housework, and shopping while set up only with tasks of managing finances and managing medication. The patient was assessed as independent with the tasks of phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The tasking tool estimated 6.42 hours of services per week. 
The insurer sent a final adverse determination denial notice stating a review of the Uniform Assessment System showed that the patient had a nursing facility level of care of 4 and therefore did not qualify for homemaker services. The patient's PCP provided a letter stating the patient required assistance with IADLs particularly, assistance with cooking, cleaning, laundry, and preparing meals and reminders for when to take medication. The letter stated the patient suffered from chronic back pain and was morbidly obese which severely impaired his mobility and performing simple IADLs could further exacerbate this pain and his shortness of breath. In addition, the letter stated the provider was advocating to attend to her patient's high needs and maximize his positive health outcomes that the patient obtain access to a home health aide. Lastly, the PCP's letter stated that she certified it was medically necessary and reasonable with reference to the excepted standards of medical practice and treatment of this patient's medical condition. 
The patient's program director for community access provided a letter stating the patient's PCP requested the urgent need for personal care assistant (PCA) services. The letter further stated the patient had numerous medical conditions severely limiting his mobility and preventing him from performing basic activities of daily living without exacerbating his chronic pain and shortness of breath. 

At issue is the medical necessity of Personal Care Services (PCS)/Home Personal Care Services 6 hours per week of homemaker services. 

Yes, the services are medically necessary. 

There is documentation from the patient's PCP of medical necessity of the PCA services to meet the patient's care needs in the community. The tasking tool did calculate 6 hours of PCA services per week for the patient. The patient has documented medical conditions which make it difficult for him to perform cooking, cleaning, laundry, and meal preparation. Based on the PCPs description of patient's medical condition and care needs, the universal assessment underestimated the patient's assistance needs for tasks of meal preparation, ordinary housework, shopping, and medication management. 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 6 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.