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202302-159172

2023

Healthfirst Inc.

Medicaid

Mental Health

Home Health Care

Medical necessity

Overturned in Part

Case Summary

Diagnosis: Social Anxiety Disorder F40.10
Treatment: Consumer Directed Personal Assistance Service for 56 Hours Per Week
The insurer denied: Consumer Directed Personal Assistance Service for 56 Hours Per Week
The denial is partially overturned.

This case involves an adult male diagnosed with social anxiety disorder associated with substantial impairments in functioning including basic and instrumental activities of daily living. The patient is requiring five to six hours of personal care assistance for meal preparation, shopping, medication administration, and his CPAP (continuous positive airway pressure) device. Additionally, the patient requires accompaniment to appointments and assistance with instrumental activities in order to maintain his home environment. Additionally, the patient's mother, with whom he lived, passed away last year which has compounded the patient's living situation. The patient's brother has stepped in to assist the patient accordingly. The requested personal care assistance services with up to 56 hours per week has been denied coverage based on medical necessity. The denial determination indicates that current allotment of five hours is sufficient for the patient's needs.

The appeal is based on the patient's functional impairments indicating that the patient needs five to six hours per day or 35 hours per week of personal assistance, and the initial request for 56 hours per week is not needed.

The proposed treatment of the requested health service/treatment of Personal Care Assistance Services with up to 35 hours per week is medically necessary for this patient.

The submitted documentation together with the case summary and other materials including the caregiver statement, clearly indicate the need for the personal care assistance, as requested. The patient's psychiatric condition together with functional impairments do require the level of assistance that has been requested in this case scenario. There is documented evidence that the patient's functioning and the psychiatric conditions have improved but may have worsened with the death of his mother. Thus, the requested benefit of Personal Care Assistance Services is medically necessary for this patient with up to five to six hours per day and 35 hours per week.

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