Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Osteoarthritis
Treatment: Home Health Care-Personal Care Assistant 
The health plan denied the requested personal care assistance hours as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient is a female with a past medical history of osteoarthritis, fibromyalgia, recurrent falls, coronary artery disease, permanent pacemaker, blindness, asthma, urinary incontinence, and cognitive impairment who underwent a telephonic assessment noting the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, and shopping while extensive assistance with phone use, stairs, transportation, equipment management, breathing, dressing upper/lower body, and toilet use. The patient was assessed at limited assistance with personal hygiene, walking, locomotion, and toilet transfer while supervision only for bed mobility and eating. Notes from this assessment stated the patient had moderate cognitive impairment and had fallen 2 months before. The patient's primary care physician (PCP) provided a letter stating the patient had been under their care for several years with multiple medical problems, with some getting worse and endangering the life and welfare of the patient. The provider requested an increase in home care hours, as the patient can no longer care for herself and is in danger of getting hurt when left alone. The insurer sent final adverse determination denial notice denying request to increase CDPAP (Consumer Directed Personal Assistance Program) hours as it was not medically necessary. The denial stated the current hours of 21 hours/week was enough to meet the patient's needs. The denial also stated the patient needs to follow up with her provider to find out what is happening to her health. In addition, the denial letter stated they would continue to approve the same hours to help with tasks of bathing, dressing, toileting, and housekeeping related services. The patient's physician provided New York Department of Health (DOH) form 4359, stating the patient's family members work 6 days/week and when the home health aide leaves the patient is left alone for hours. The patient is sitting in soiled diapers for hours and falls an average of 5 times/week. The 4359 form also stated the patient is unable to transfer without assistance and is unable to feed herself with the need to be spoon fed. The patient has had unintentional weight loss. 

At issue is the medical necessity of the requested personal care assistance hours.

The health plan's determination of medical necessity is overturned, in whole.

The patient has documented chronic medical diagnoses of osteoarthritis, cognitive impairment, coronary artery disease, and is blind. The patient's PCP provided additional information on the DOH 4359 form, stating the patient's family is not able to provide informal care due to their work schedules and the patient is not able to transfer without assistance. In addition, the patient is not able to feed herself. The increase in CDPAP service hours is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living (ADLs)/instrumental activities of daily living (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, CDPAP services 31 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.