Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Hip Problem/Pain.
Treatment: Consumer Directed Personal Assistance: Total of 35 Hours per Week.

The health plan denied: Consumer Directed Personal Assistance: Total of 35 Hours per Week.
The determination is Upheld.

The patient is a male with a medical history notable for chronic left hip pain, low back pain, and mobility issues. The patient is approved for 7 hours per week of consumer-directed personal assistance. The patient and his care team requested an increase to 35 hours per week, and this request was denied by the health plan. This denial is the subject under review.
The patient's orthopedic surgeon provided a letter of support for this appeal. The letter states that the patient had left hip arthroscopy with labral repair and has reached a recovery plateau after one year of rehabilitation including physical therapy and medical management. The patient is unable to walk or ambulate without a limp. This limits his ability to perform activities of daily living. The physician states that this disability is permanent and irreversible. He is a significant fall risk secondary to his left leg weakness. The physician states that he cannot drive, walk independently, cook, clean, shop, bathe, or complete hygiene without assistance.
The most recent office visit notes were provided for review. There were no further interventional procedures planned for the patient. He was deemed to be appropriate for weight-bearing as tolerated. He was instructed to transition from a walker to a cane as tolerated.
A Uniform Assessment System (UAS) was completed. The assessment was conducted via video teleconference. The patient lives in a private home with his girlfriend. His cognitive skills were intact. For instrumental activities of daily living, the patient requires total dependence on meal preparation, housework, and finances. He is otherwise limited to assistance or independence for the remainder of the instrumental activities of daily living (IADLs). For his activities of daily living, the patient requires limited assistance for bathing, bed mobility, and dressing his lower body. He is independent in other domains. The patient's significant other has been preparing meals for the patient and performing ordinary housework. He can ambulate with a walker and transfer on and off the toilet without assistance. He reported he was able to perform hygiene without assistance. The patient is continent of urine and stool. There was no fall in the previous 90 days. A task tool associated with the assessment recommended 6.23 hours per week to address the patient's personal care needs, including time allotted for meal preparation, housework, bathing, dressing lower body, and transportation to appointments.
The health plan's determination of medical necessity is upheld as whole.
The requested health service of Consumer Directed Personal Assistance: A Total of 35 Hours per Week has not been demonstrated to be medically necessary for this patient.
The patient has some functional limitations secondary to left leg pain as outlined in the physician notes and the assessment. His limitations revolve primarily around IADLs. He does require some assistance with bathing and dressing his lower body due to pain as well. Providing for these needs could be done in a relatively modest number of hours per week. The task tool recommended approximately 7 hours per week, which was granted by the health plan. The allotment of hours accommodates all of the areas of required assistance. The documentation provided does not demonstrate that there are currently any unmet personal care needs. The physician states that the patient is at high fall risk, but there were no falls in the previous 90 days, and safety monitoring is not a covered function of a personal care aide. Therefore, the requested increase to 35 hours per week has not been demonstrated to be medically necessary for the patient.