Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ataxia/Inability to coordinate voluntary muscular movements
Treatment: Personal Care Assistance, a total of 56 hours per week

The health plan denied: Personal Care Assistance, a total of 56 hours per week
The determination is: Overturned

This is a case review for a female with medical history notable for urinary incontinence, history of falls, gait abnormalities, and diabetes. The patient is approved for 35 hours per week of personal care services. The patient and her care team requested an increase to 56 hours per week, and this request was denied by the health plan. This denial is the subject under review.
The patient's daughter provided a letter of support for this appeal. The letter states that the patient requires assistance with walking, transfers, dressing, hygiene, toileting, incontinence care, and managing medications. The patient's daughter has a full-time job and is not available for assistance during the day. There is no other informal support available during the workday. Therefore, she is requesting an increase in personal care hours to allow for adequate coverage during the time when the patient is left alone and cannot complete any activities of daily living without assistance.
A Uniform Assessment System was most recently completed via teleconference. The patient's memory was minimally impaired. She was alert and oriented to person and place only. She was self-directing with episodes of forgetfulness. For her instrumental activities of daily living, the patient requires total dependence for housework. She requires maximal assistance for shopping, stairs, medications, and meal preparation. She requires extensive assistance for finances and transportation. For activities of daily living, the patient requires extensive assistance for bathing, dressing her lower body, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for hygiene and dressing her upper body. She is independent for bed mobility and eating. The notes state that the patient does require assistance with ambulation. She is frequently incontinent of urine and uses Pull-Ups for incontinence care. There was one fall in the previous 30 days. There was no pressure ulcer present. Compared to a prior assessment, the patient showed a decline in functional status.
At issue is the medical necessity of Personal Care Assistance, a total of 56 hours per week.
The health plan's determination of medical necessity is overturned in whole.
The requested health service of Personal Care Assistance, a total of 56 hours per week is medically necessary for this patient.
The patient requires hands-on personal assistance with nearly all activities of daily living, including transfers, ambulation, toileting, and incontinence care. This is reflected in both the assessment and the letter from the patient's daughter. These care needs can be expected to be continuous and unscheduled throughout the day. As outlined in the letter, the patient does not have any informal support during the workday due to full-time working obligations of her family. Therefore, the requested increase to 8 hours per day is medically necessary and reasonable for the patient. This will allow adequate coverage during the day for any personal care needs that should arise, including unscheduled needs like toileting and incontinence care. The patient's fall within the past month is evidence of unmet personal care needs, as she may be attempting to complete tasks when an aide is not available. Failure to provide for the patient's personal care needs could result in additional falls, infection, and/or skin breakdown. Therefore, the requested increase is medically necessary.