Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, hypertension, anemia, hyperlipidemia, Parkinson's Disease (PD), and osteoarthritis

Treatment personal care aide (PCA) level 2: 8 hours per day- 5 days per week; 5 hours per day- 2 days per week- for a total of 50 hours per week,

The insurer denied coverage for personal care aide (PCA) level 2: 8 hours per day- 5 days per week; 5 hours per day- 2 days per week- for a total of 50 hours per week.

The denial is overturned.

The patient has the medical diagnoses of heart disease, hypertension, anemia, hyperlipidemia, Parkinson's Disease (PD), and osteoarthritis. The treating provider requesting plan approval for personal aide.

According to the clinical documentation provided for review, the treating provider is requesting plan approval for personal aide. The patient has the medical diagnoses of heart disease, hypertension, anemia, hyperlipidemia, Parkinson's Disease (PD), and osteoarthritis. The patient has been seen and treated for a past medical history (PMH) including but not limited to heart disease, hypertension (HTN), anemia, hyperlipidemia, Parkinson's Disease, and osteoarthritis (OA). The patient requested an increase in personal care aide to the amount of 50 hours per week. The patient lives alone and the patient is by himself. The patient has been falling a lot. The patient's been hospitalized, due to falls. The patient needs assistance go up and down the stairs or to the bathroom, house cleaning, shopping, and making dinner. The decision was to deny the request for an increase in services. The approval was for 28 hours per week. The patient has a personal response system. The patient has been hospitalized several times for falls with varying injuries. The patient was seen at the psychiatry outpatient clinic, which was documented that the patient has a fall risk and fell at home. The note indicates the patient was seen and was noted to have hypertension and dementia and was admitted to the emergency department after falling at home. The treating provider ordered personal aide.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

This patient has clear cut emotional and physical deficits, Parkinson's, dementia, unsteadiness, and arteriosclerotic heart disease. The patient lives alone. The patient has already fallen requiring hospitalization, several times. The requested increase in hours for health aide is medically appropriate and necessary for his function and safety.      

Personal care aide (PCA) level 2: 8 hours per day- 5 days per week; 5 hours per day- 2 days per week- for a total of 50 hours per week considered medically necessary for this patient.

"Home health care is a system of care provided by skilled practitioners to patients in their homes under the direction of a physician. Home health care services include nursing care; physical, occupational, and speech-language therapy; and medical social services.1 The goals of home health care services are to help individuals to improve function and live with greater independence; to promote the client's optimal level of well-being; and to assist the patient to remain at home, avoiding hospitalization or admission to long-term care institutions.24 Physicians may refer patients for home health care services, or the services may be requested by family members or patients." (Ellenbecker, et al., 2008).

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a personal care aide (PCA) level 2: 8 hours per day- 5 days per week; 5 hours per day- 2 days per week- for a total of 50 hours per week is overturned. Medical Necessity is substantiated.