Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neuropathy
Treatment Personal care services level 2 personal care services, per 15 minutes increase to 49 hours per week
The insurer denied personal care services level 2 personal care services, per 15 minutes increase to 49 hours per week.
The determination is overturned.

The patient has a past medical history of diabetes mellitus (DM) type 2-insulin dependent, hypertension, benign prostatic hyperplasia (BPH), gastroesophageal reflux disease (GERD), gout, osteoarthritis and neuropathy and had been assigned 28 hours/week of personal care aide (PCA) services based on assessment tools. The assessment noted the patient to be independent with tasks of managing finances, managing medication, phone use, personal hygiene, walking, locomotion, transfer toilet, toilet use, bed mobility and eating, requiring limited assistance with tasks of bathing and dressing upper and lower body, requiring extensive assistance with tasks of meal preparation, stairs and transportation, and requiring maximum assistance with tasks of ordinary housework and shopping. There was a request for an increase in PCA service hours. The patient had a phone assessment due to the COVID 19 pandemic, noting the patient had a fall the day before. His daughter had to come to help him get up. There was no answer on the assessment to "Are you experiencing any change in your condition or new diagnosis". The patient wrote a letter stating that he has fallen three times in the last month, is unstable when alone during the day, cannot care for himself like he did in the past, cannot stand for more than a few minutes and cannot walk up the stairs alone. On the same date, there was a note from the patient's primary care physician (or provider) (PCP) stating the patient fell on 3 different days and that each fall resulted in injury. The letter also noted that there has been a significant cognitive decline with altered mental status and he was unable to care for activities of daily living (ADLs) as previous. In addition, the letter stated the patient has poor balance and fine motor skills requiring more support from the caregiver and that he cannot shop, cook or clean. There was a final adverse determination letter from the insurer stating his PCA services hours would remain at 4 hours/day, 7 days/week to total 28 hours/week. At issue is the medical necessity of personal care services level 2 personal care services, per 15 minutes increase to 49 hours per week.

The requested personal care services are medically necessary. The patient had assessment tools performed noting assistance needs which were deemed independent with walking and locomotion. The patient had 3 falls in a one month period of time due to the progression of neuropathy, worsening arthritis and noted worsening cognition. The patient had a telephonic assessment when there was a request for increased PCA service hours which underestimated the patient's PCA service needs as he required more assistance with ADL tasks than assessed during his assessments. The patient had a change in his condition from the prior assessments and this was not addressed during his telephonic assessment. The patient's PCP wrote a letter supporting the need for increased help with ADLs and instrumental activities of daily living (IADLs). The patient would have a higher assistance need for most ADL and IADL tasks.