Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension (HTN), anemia, gastroesophageal reflux disease (GERD), magnesium/vitamin deficiency, asthma, allergic rhinitis, sarcoidosis, fibromyalgia, edema, falls, insomnia, pain, and unsteady gait. 
Treatment: Consumer directed personal assistant services, a total of 30 hours per week. 
The insurer denied coverage for consumer directed personal assistant services, a total of 30 hours per week. 
The denial is overturned. 

This case involves an adult female regarding the denial of coverage for consumer directed personal assistant services, a total of 30 hours/week. An assessment was conducted over 1 year ago which noted the patient had frequent falls, limited impairment, edema, shortness of breath with poor health but believed that she was capable of increased independence in terms of meal prep, housework, shopping, transportation, and reported short-term memory, which needed assistance with personal hygiene and transfers. The patient had a low depression rating score, reports of pain, and sometimes felt lonely. The patients child was helping with cooking and she reported having sarcoidosis and the development of fibromyalgia. The patient had a heart monitor placed 3 years ago and needed assistance with daily tasks for safety in the home and community. The patient lives in a private home with children. There were no Emergency Room (ER) visits or hospitalizations in the last 5 years. The patient was independent for decision making, managing finances, phone use, walking, locomotion, toilet use, bed mobility, eating and had an intact memory. The report stated the patient needed maximal to total dependence for meal preparation and ordinary housework. The patient needed set-up help only for managing medications. The patient required extensive assistance for navigating stairs, shopping, transportation as well as bathing and dressing the lower body and toilet transfer. The patient needed limited assistance for personal hygiene and was able to perform dressing the upper body with set-up help only. The patient used an assistive device for walking/locomotion. The patient reported 2 or more falls in the last 30 days with minor injuries. 

Personal assistant services (PAS) allow patients to remain in their own home to receive care/treatment rather than residing in a skilled nursing facility, long-term acute care, or assisted living. The documentation noted the patient had multiple health concerns and needed assistance with activities of daily living (ADL) and instrumental activities of daily living. The patient was previously approved for 13 hours of PAS per week but was requesting an increase to 30/week given that the patient was typically relying on her child to assist with her needs. The assessment conducted over 1 year ago noted the patient had multiple diagnoses causing impairments in her ability to complete daily tasks, and had suffered multiple falls and had no evidence of significant improvement in her condition. 

Given the provided information, it was determined that the increase in hours would be reasonable to meet the needs of the patient.  However, given that the assessment is now over a-year-old, an updated assessment will need to be obtained within 30 to 60 days to determine the extent of the patient's condition given that the patient felt that she was capable of improving her functionality. After a review of the provided information, the Consumer Directed Personal Assistance services, a total of 30 hours per week is medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Consumer Directed Personal Assistance services, a total of 30 hours per week services is substantiated.