Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 

The insurer denied Consumer and Self-directed Personal Assistance Services. 
The denial is partially overturned. 

This patient is a male with a history of bipolar disorder and schizophrenia. He has multiple sclerosis and morbid obesity. The patient's condition has deteriorated leading to severe difficulty with ambulation and standing. This is related to pain, weakness, and numbness in both lower extremities and also creates very poor balance. He now requires hands-on assistance with dressing of the upper body, transferring on and off the toilet and adult diaper changes. He ambulates with a walker and wheelchair and always needs caregiver assistance to ambulate. There were no nighttime needs commented on. He has daily episodes of bowel and bladder incontinence. He requires maximal assistance with meal preparation, housekeeping, laundry, shopping, dressing, personal hygiene, toileting, and bathing. He is totally dependent for ordinary housework and requires maximal assistance for shopping. He is able to eat and move about in his bed on his own. He requires maximal assistance with bathing and some assistance with personal hygiene. He needs maximal assistance with dressing his lower body. He requires extensive assistance with transferring to the toilet and maximum assistance with toileting. He is independent with eating. The patient is able to self-administer medications but does at times require assistance opening medication bottles. The HELPS Assessment Report recommended 42 hours/week, 7 days a week.
At issue is the medical necessity of Consumer and Self-directed Personal Assistance Services, 84 hours a week. 

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

The requested health service/treatment of Consumer and Self-directed Personal Assistance Services, 84 hours a week is not medically necessary for this patient, however, 42 hours/week is medically necessary. 
 
The health plan failed to follow with the recommendations provided by caregivers, requesting 42 hours/week and totaling services 7 days/week. Presently the patient is only receiving services 6 days/week. This is inadequate due to his care needs. The care needs outlined in the documentation may not be around the clock, but they are daily. This includes assistance with grooming, toileting, transferring and ambulation. These are daily tasks and thus the plan should be providing services 7 days/week. The plan failed to follow with the recommendations, requesting 42 hours/week and totaling services 7 days/week. Presently the patient is only receiving services 6 days/week. 

With his medical and psychiatric conditions including impact on ambulation, transferring, toileting, meal preparation and at times accessing his medications, providing services less than every single day is medically inappropriate and places the patient at increased risk of harm, morbidity, and mortality. It is clearly demonstrated that the patient has care needs that occur on a daily basis and 6 days/week is insufficient and unacceptable. It would be appropriate and medically necessary to provide services to this patient at 42 hours/week, 7 days/week. This would be consistent with the assessment performed. Their assessment demonstrated a need of 42 hours/week and 7 days/week of care.