Appeal type: Medical necessity
Decision: Upheld

Respiratory System/Asthma
Home Health Care/Personal Care Aide 7 days x 12 hours
The health plan denied the requested Personal Care Aide 7 days x 12 hours as not medically necessary. The health plan's determination is upheld.

This is a case review for a female with a medical history notable for ambulatory dysfunction, coronary artery disease, and incontinence. The patient is approved for 3 hours per day, 7 days per week (21 hours per week) of personal care aide services. The patient and her care team requested an increase to 12 hours per day, 7 days per week.
Case management notes were provided for review. The notes state that the patient's granddaughter expressed concern over the patient living alone and requested additional aide hours. She reported that the patient has been more confused lately and is not able to prepare meals alone. The case manager placed a referral for a meal delivery program which was subsequently approved. The granddaughter lives two hours away and the patient's daughter lives one hour away and they are the emergency backup plan. The nursing home waiver program was offered to the patient's family who declined.
An independent advocacy organization provided a letter of support for this appeal. The letter was reviewed in detail.
The patient's physician provided a letter of support for this appeal. The letter states that the patient lives alone and does not have informal support. The patient requires furosemide, which requires increased toileting. The physician states that the patient needs some to total assistance with activities of daily living including bathing, dressing, shopping, meal preparation, and prompting. The physician recommends an increase in personal care hours.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person. The patient lives alone in an apartment. She was alert and oriented. Her recall was 2/3 at five minutes. She is able to describe procedural tasks and direct her own care. For her instrumental activities of daily living (IADL), she requires extensive assistance for housework and shopping. She requires limited assistance for meal preparation. Other IADL are independent. For her activities of daily living (ADL), she requires limited assistance for bathing and dressing. Other ADL are independent. She is occasionally incontinent of urine (less than daily) and uses liners as needed. She is able to manage incontinence episodes herself. A task tool associated with UAS recommended 21 hours per week to address her needs.
At issue is the medical necessity for the requested health service/treatment of a Personal Care Aide 7 days x 12 hours.

The health plan's determination of medical necessity is upheld, in whole.

The requested health service/treatment of Personal Care Aide 7 days x 12 hours has not been demonstrated to be medically necessary for this patient.
The UAS demonstrates that the patient's personal care needs are limited to only a few categories, which is also consistent with the description provided in the physician letter. The patient requires assistance with meal preparation and housekeeping. For her ADL, she requires some assistance with dressing and bathing. She is able to manage her infrequent episodes of incontinence by herself according to the documentation. The task tool recommends 3 hours per day to address these needs, which is a reasonable amount of time to address those tasks. She is independent for other personal care needs. Additional hours cannot be granted for the purposes of safety monitoring and security, as those are not allowable personal care functions. There is no evidence of personal care needs that are not being met by the patient's current allotment of aide hours.