Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary incontinence
Treatment: Increase in personal care services to 12 hours (hrs) a day, 7 days a week, a total of 84 hrs a week
The insurer denied an increase in personal care services to 12 hours (hrs) a day, 7 days a week, a total of 84 hrs a week.
The determination is overturned.

This is a male patient with a medical history notable for urinary incontinence, renal insufficiency, prior cerebrovascular accident, and glaucoma with legal blindness. The patient is approved for 9 hours per day, 7 days per week (63 hours per week) of personal care services. The patient and his care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient is homebound and bedbound and requires home care throughout the day and night to meet his personal care needs. He requires extensive or maximal assistance for activities of daily living including transfers, toileting, and ambulating. He has no informal help or support. The physician's office visit notes were also provided for review. The notes discuss that his current level of care is not adequate to meet his needs, and that if his hours are not increased "his medical wellbeing will be compromised at home."
A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted via teleconference. The patient lives at home with his elderly spouse. The patient was alert and oriented times two; he was forgetful with periods of confusion. He is able to make simple needs known but not able to call for help in an emergency. For his Instrumental activities of daily living (IADLs), he requires total dependence for meal preparation, housework, shopping, and transportation. He requires maximal assistance for finances, medications, phone use, and stairs. For his activities of daily living (ADLs), he requires maximal assistance for nearly all, with the exception of requiring extensive assistance for bed mobility and eating. He spends most of the time lying in bed and is able to walk for short distances with a walker and human assistance. He requires assistance with all transfers including toileting. He is frequently incontinent of urine and uses pull up diapers for incontinence care. A task tool associated with the assessment recommended 64.5 hours per week to address his personal care needs.
A detailed activity report was provided for review. The report displays numerous instances that the patient was found on the floor of the bedroom and unable to get up without assistance.
At issue is the medical necessity of an increase in personal care services to 12 hours (hrs) a day, 7 days a week, a total of 84 hours a week.

The requested health service of increase in personal care services to 12 hours a day, 7 days a week, a total of 84 hours a week is medically necessary for this patient.
The patient is bed bound and unable to complete any ADLs without personal care aide assistance. He has had numerous documented falls which attest to a failure to provide for his personal care needs when he is left unattended. He requires assistance with toileting and also has urinary incontinence; it is reasonable to expect that he will have personal care needs that are unscheduled throughout the day. There is ample evidence of the medical necessity to increase the personal care hours to 12 hours per day as requested. Failure to provide for his personal care needs could result in additional falls, infections, and/or skin breakdown.