Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Increase in personal care services (10-11 hours a day, 7 days a week, totaling 70-71 hours)
The health plan denied the requested increase in personal care services (10-11 hours a day, 7 days a week, totaling 70-71 hours) as not medically necessary. The health plan's determination is overturned. 

The patient is a female with a medical history notable for bilateral knee arthritis with associated pain, hypothyroidism, Zenker's esophagus with difficulty swallowing, atrial fibrillation, left leg vein ablation, and history of poor wound healing. She was approved for 7 hours per day, 7 days per week (49 hours per week) of personal care services. The patient and her care team requested an increase to 10-11 hours per day, 7 days per week, for a total of 70-71 hours. 
A letter was provided by the primary care physician who has been caring for the patient for 4 decades. It states that she has urinary incontinence and wears pull ups and requires assistance for changing. She is at high risk for skin breakdown. She needs assistance with eating due to swallowing difficulties secondary to the Zenker's esophagus. She requires assistance when changing positions. She has orthostatic hypotension and requires assistance while standing and ambulating. The physician recommended additional personal care time as medically necessary.
A letter was provided by the patient's daughter and notes that the patient's health has deteriorated significantly. She is alone from 4pm until the aide arrives the next morning. She is unable to ambulate alone due to pain and orthostasis, and so throughout that time, she does not receive any meals/nutrition. Her daughter expresses concern that "all her actions are unmonitored for safety."
A letter was provided by the patient's treating physician. The letter states that under her current aide hours, she does not have assistance to help with her evening meal, evening medicines, or with changing clothes for bedtime.
A Uniform Assessment System (UAS) was completed and was available for review. It found her to have modified independence with cognition, and that she is able to call 911 in an emergency. She requires total dependence for housework. She requires maximal assistance for meal preparation, stairs, shopping, and transportation. She requires set up help with finances, medication, and phone use. For her activities of daily living (ADL), she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for hygiene, dressing her upper body, walking, locomotion, toilet transfer, and toilet use. She is independent in bed mobility and eating. She is occasionally incontinent of urine and is continent of stool. An Hours Evaluation for Paraprofessional Support (HELPS) assessment associated with the UAS recommended 41 hours over 7 days per week.
At issue is the medical necessity of the requested increase in personal care services.
The health plan's determination of medical necessity is overturned in whole.
The requested increase in personal care services (10-11 hours a day, 7 days a week, totaling 70-71 hours) is medically necessary for this patient.
The patient's primary care physician and the medical director for her home care services attested that she has medical needs that were underrepresented by the UAS. They assert that the patient is not independent in eating and with managing medications, and that she medically requires assistance with those tasks. This patient primarily has functional deficits in ADLs to her mobility issues. She requires assistance with dressing and toileting. It is not reasonable to expect her to go 17 hours between aide shifts without assistance in managing this. Having the aide stay for 10-11 hours per day would ensure proper assistance with meals, medications, toileting, and dressing, all of which are personal care tasks. These hours would not be used for safety monitoring and supervision alone.