Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain, Hip Pain, Pregnancy
Treatment: Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (live in)
The insurer denied home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (live in).
The determination is overturned.

The patient has a past medical history of pregnancy, gestational diabetes, scoliosis, human leukocyte antigen (HLA) B27 positivity, depression, anxiety, bipolar disease, obsessive compulsive disorder, post traumatic stress disorder, and insomnia who had been assigned consumer directed personal assistance program (CDPAP) services 32 hours/week based on an assessment assessing the patient at extensive assistance with the tasks of meal preparation and shopping while limited assistance with the task of ordinary housework. The patient was assessed at supervision with the task of managing finances and set up only with the tasks of managing medication and transportation. With the tasks of phone use, stairs, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating the patient was assessed at independent. There was a request to increase personal care assistant (PCA) services and the patient underwent another assessment assessing the patient at extensive assistance with the tasks of meal preparation, ordinary housework, and shopping while supervision with task of managing finances. The patient was assessed at set up only with the tasks of managing medication and transportation while independent with all other tasks. Notes from the assessment stated the patient was requesting help with cooking, cleaning, ambulation, assistance with bathing, and assistance with dressing. The assessment also stated the patient had a coronavirus disease (COVID) infection and her functional abilities had declined after this infection and that the patient had no informal helper.

The insurer sent an initial adverse determination denial notice denying the request to increase personal care assistant (PCA) service, stating there was no change in activities of daily living (ADLs) within the last 90 days, no change in overall self-sufficiency, and no documented change in the patient's clinical condition or change in social circumstances. The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating the patient had no loss of motor function, it was not medically necessary to increase the patient's PCA services, the recent assessment demonstrated no changes with her physical functioning compared to prior assessment, and hours beyond those currently authorized would be for safety monitoring which is not a covered benefit. They did increase hours to 33 hours/week. A physical therapy note stated the patient was being seen for low back pain, scoliosis, bilateral hip pain, bilateral shoulder pain. The notes from the physical therapy assessment stated the patient had functional limitations with remaining standing, instrumental activities of daily living (IADLs), walking around in different locations, walking down the street, and had pain at 5 out of 10 with activities.

The patient's medical provider provided a letter stating the patient was pregnant and it was recommended that the patient receive an increase in home attendant hours for overall safety of the patient and her unborn child. The provider noted the patient became anxious, depressed, and fearful when alone and was unable to increase medications for these conditions as she intends on breast-feeding postpartum. Lastly, the provider stated that based on their clinical judgment the patient would benefit from a minimum of 10 hours/day to assist her in her last trimester and during her postpartum period to ensure the health of both mother and baby. The patient appealed the denial decision. The patient's rheumatologist provided a letter stating the patient had a history of thoracolumbar scoliosis, chronic pain, and positive HLA-B27 test with complaints of throbbing pain in the body, back, legs, arms, shoulders, and morning stiffness. The provider also stated the patient was 33 weeks pregnant and had difficulty functioning, walking, standing, preparing meals, and doing laundry. Lastly, the medical provider stated it was medically necessary for the patient to have a home health aide for up to 12 hours/day, 7 days/week, to support and improve quality of life. The patient's medical provider appealed the denial decision. The insurer sent notice that a fair hearing was scheduled. The patient's obstetrician provided a letter noting the patient had gestational diabetes and would need to monitor her glucose for the rest of the pregnancy. The patient's healthcare advocate provided a letter for requesting an external appeal of denial decision. A summary of this letter stated the plan had not considered how the member's pregnancy had exacerbated her pre-existing conditions, the practice recommendations from her treating providers, and the fact that she required cognitive prompting, cueing, and supervision for most (if not all) ADLs.

At issue is the medical necessity of home care/personal care (HHC)- level 2 personal care services, per 15 minutes increase to 24 hours per day (live in).

The services are medically necessary. There is documentation from the patient's rheumatologist of a need for increased PCA services due to progression and worsening of the patient's underlying musculoskeletal pain with progression of the patient's pregnancy. Despite physical therapy the patient continued to have an escalation of pain. The patient's last assessment underestimated the patient's care needs as she was early in her pregnancy and her symptoms worsened as her pregnancy progressed with limited mobility and she was no longer independent with ADLs. Her medical providers documented the medical necessity of increased PCA services. The patient is unable to take pain medication to control her pain because of her pregnant condition. In addition, the patient was diagnosed with gestational diabetes and required cueing to check her blood sugars on a regular basis. Similarly, because of the severity of her mental health diagnoses she required cueing to take her medications regularly. The patient has no informal help. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. 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 24 hours/day, live-in, 7 days/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 her own home.