Diagnosis: Infectious disease/other
Treatment: Home health care
The insurer denied the requested 12 hours per day, 5 days per week and 5 hours per day, 2 days ; total 70 hours per week.
The denial is overturned in whole.

The patient is a female with a past medical history of asthma, coronary artery disease, hypertension, congestive heart failure, gastroesophageal reflux disease (GERD), constipation, osteoarthritis, low back pain, transient ischemic attack (TIA), vertigo, incontinence, history of breast cancer and frequent falls.
Yes, the requested Personal care assistance 12 hours per day 5 day per week and 5 hours per day for x2 day total 70 hours per week is medically necessary.
The patient had a significant change in health following 2 hospital admissions with the requirement of nebulized medication, oxygen therapy 24 hours per day and BIPAP therapy. This change in status was not documented in her most recent assessment tool. There was limited documentation regarding the new oxygen order, nebulized medication or BIPAP. The patient requires assistance with equipment management, walking and locomotion due to the new therapies and her needs. The patient walks with a cane and is at risk for fall/tripping due to oxygen tubing. The patient's recent hospitalization increased her need for follow up visits with medical providers and transportation needs. Her PCP noted the medical necessity of increased PCA service hours in the two letters submitted for review.