Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain due to fall.
Treatment: 70 hours per week (10 hours per day, 7 days per week) of Consumer Directed Personal Aide Service.
The insurer denied 70 hours per week (10 hours per day, 7 days per week) of Consumer Directed Personal Aide Service.
The determination is upheld.

This patient is a male with a past medical history notable for coronary heart disease, schizophrenia, and a recent fall with resulting pain. The patient is approved for 52 hours per week (6 days per week at 7 hours per day, and one day per week at 10 hours per day) of Consumer Directed Personal Aide Service (CDPAS). The patient and the care team requested an increase to 70 hours per week (10 hours per day, 7 days per week). A letter of support for this appeal was provided by the patient's physician. The letter states they are requesting an increase in hours however it does not discuss any unmet personal care needs or medical necessity.

Case review notes from the patient's social worker were provided for review. They report that the patient was working with physical therapy weekly in early 2022 with a goal of ambulating independently. In addition, the patient was working on losing weight. The patient suffered a fall while ambulating to the physician's office which is a half block away. The patient saw pain management and had a magnetic resonance imaging (MRI) of the hip. The patient reported pain had improved. Later, the patient expressed discontent with the denial of increased hours due to concerns over their functional status secondary to pain after the fall.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to be independent cognitively and able to direct their own care. From a functional standpoint, they require maximal assistance for meal preparation, housework, stairs, shopping, and transportation. The patient is independent with managing medications and finances. For activities of daily living (ADL), the patient requires maximal assistance for bathing, walking, locomotion, and toilet use. The patient requires extensive assistance for dressing upper and lower body as well as toilet transfer. The patient requires limited assistance for hygiene. The patient is independent for bed mobility and eating. At the time of the evaluation, the patient was no longer able to ambulate with a walker or cane due to pain in the hip radiating down the legs. The patient is frequently incontinent of urine and stool. The patient wears disposable briefs and uses a urinal and bedpan.

Compared with a prior Uniform Assessment System (UAS), the patient showed an improvement in level of assistance required in the following domains: meal preparation, housework, stairs, shopping, transportation (all of which had been total dependence). The activities of daily living (ADL) had increases and decreases in functional status. A task tool associated with the most recent assessment recommended 41 hours per week to address functional needs. At issue is the medical necessity of home health services.

The requested health service/treatment of Consumer Directed Personal Aide Service (CDPAS) 7days x 10 hours is not medically necessary for this patient. The patient is approved for 52 hours per week of Consumer Directed Personal Aide Service (CDPAS), which is 10 more hours per week than the task tool recommended to meet his functional needs. There is no documentation of unmet personal care needs, which would necessitate an increase in personal care hours. The patient suffered a fall which did impact their functional ability, but the Uniform Assessment System (UAS) was performed shortly after that fall and should reflect any deficits due to subacute injury.