Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Personal care assistance, total of 40 hours per week 
The insurer denied personal care assistance, total of 40 hours per week. 
The determination is overturned.

The patient has a past medical history of chronic complex partial seizures, osteoarthritis, and right foot fracture who had been assigned personal care assistant (PCA) services 8 hours/day, 3 days/week, to total 24 hours/week based on an assessment.

The patient's primary care physician (PCP) provided a letter stating the patient would benefit from increased home health aide hours. There was a request to increase PCA services and the patient underwent an assessment tool assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, stairs, transportation, and equipment management. The patient was assessed at limited assistance with the tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use while set up only with task of phone use. With the tasks of bed mobility and eating the patient was assessed at independent. The patient scored 25/30 on a Mini-Mental State Examination (MMSE). The patient's neurologist provided a letter stating the patient had focal epilepsy secondary to a right cerebral cavernoma and was treated with two medications, but despite this treatment the patient continued to have 2-4 brief focal aware seizures weekly. The neurologist requested extended hours, 9-5 Monday-Friday for her home health aide for her safety. The neurologist's letter further stated that the patient's seizures may present with staring, automatisms, loss of awareness or right sided shaking which may be a danger while traveling outside, cooking, or cleaning. Lastly, the neurologist's letter stated extended hours would provide time for the aide to help the patient with activities of daily living including accompanying her to the store and doctor appointments.

The insurer denied the appeal, stating the hours provided under her last authorization or reauthorization were still enough to meet her needs. This denial also stated safety supervision is not required to be covered as a separate or a stand-alone function. The patient's PCP provided a letter stating the patient's seizures pose a danger to her both indoors and outdoors.

At issue is the medical necessity of personal care assistance, total of 40 hours per week. 

The patient requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs) except bed mobility and eating. The patient requires assistance outside of the hours she has 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/IADLs. The patient's care needs cannot be met solely with medical supplies and adaptive equipment. 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 40 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 her own home.