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PA Packet Review #auth-101

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Patient Summary

Maria Gonzalez

Medicaid ID: 9876543210 • DOB: 1954-06-12

TX STAR+PLUS

Primary ICD-10: M79.7 — Fibromyalgia with severe polyarthralgia

Extracted Data Fields

Confidence Scores

Patient Name

Maria Gonzalez98% (High)

Medicaid ID

987654321092% (High)

Physician NPI

123456789090% (High)

Requested Service

18 hours/week85% (High)

Homebound Status

Documented (YES)65% (Verify)

Uploaded Clinical Documents

📄 test-oasis.txtOASIS Assessment

📄 test-physician-orders.txtCMS-485 Plan of Care

📄 test-clinical-notes.txtClinical Progress Note

TX STAR+PLUS Prior Authorization Packet

Preview generated 4-page clinical packet

Medical Necessity Justification (500+ Words Clinical Narrative)

Editable by Coordinator

CLINICAL MEDICAL NECESSITY JUSTIFICATION

1. PATIENT CLINICAL PRESENTATION & PRIMARY DIAGNOSIS:
The member, Maria Gonzalez (DOB: 06/12/1954, Medicaid ID: 9876543210), is a 72-year-old female presenting with primary diagnosis M79.7 (Fibromyalgia with severe polyarthralgia) complicated by secondary osteoarthritis and essential hypertension. The primary diagnosis creates severe physical functional impairment affecting major daily activities.

2. LEVEL OF CARE (LOC) NURSING FACILITY DETERMINATION:
Member meets Nursing Facility Level of Care (LOC) criteria under Texas STAR+PLUS HCBS guidelines due to hands-on assistance requirements in 4 out of 5 core ADLs: bathing (M1810=3), dressing (M1820=2), transferring (M1830=2), and ambulation (M1860=3).

3. DANGERS OF NON-APPROVAL & PREVENTABLE MEDICAL RISKS:
Without 18 hours/week of personal attendant support, the member faces imminent risk of falls, medication non-adherence, skin breakdown, nutritional neglect, and emergency hospitalization leading to institutional nursing home placement.

4. PRESCRIBED SERVICE FREQUENCY & CARE PLAN RATIONALE:
Requested 18 hours per week of Personal Attendant Services (PAS, Procedure Code: S5125) are medically necessary and non-duplicative of community resources. Hours are scheduled across morning hygiene, meal preparation, and evening transfers.

5. PHYSICIAN ATTESTATION:
I attest that personal attendant services are medically necessary and prescribed per Texas Medicaid regulations.
Authorized by: Dr. Robert Chen, MD (NPI: 1234567890)

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