Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis. 
Treatment: 56 hours per week of Personal Care Aide. 

The health plan denied: 56 hours per week of Personal Care Aide. 
The determination is upheld. 

The patient is a female with medical history notable for prior cerebrovascular accident, coronary artery disease, hypertension, paroxysmal atrial flutter, uncontrolled type 2 diabetes, and urinary and fecal incontinence. The patient is approved for 42 hours per week of consumer directed personal care aide. The patient and her care team requested an increase to 56 hours per week. 

The patient's colorectal surgeon provided a letter for this review. The letter states that the patient has fecal incontinence and because of this, she would benefit from greater assistance in her home care. There were no details provided on any unmet personal care needs. 
An office visit note with the patient's primary physician was provided for review. The physician comments that the patient's daughter is requesting increased hours due to being unsteady with her walker and needing more assistance. She "continues to state that patient needs help with instrumental activities of daily living (IADL), as well as assistance transferring in and out of bed and with toileting." There is no further detail on any personal care tasks that cannot be met with the current allotment of hours.
A Uniform Assessment System (UAS) was completed and available for review. The assessment was conducted via teleconference with the patient's daughter present. The patient was self-directing; she was alert and oriented with periods of forgetfulness at times. For her IADL's, the patient requires maximal assistance with meal preparation, housework, and shopping. She requires extensive assistance for transportation. For her activities of daily living (ADL), she requires maximal assistance with dressing her lower body. She requires extensive assistance for bathing, dressing her upper body, walking, locomotion, and toilet use. She requires limited assistance for hygiene and toilet transfer. She is frequently incontinent of urine. The UAS stated that she was continent of stool at the time, although fecal incontinence was documented in more up-to-date physician notes. A task tool associated with the UAS recommended 29.7 hours per week to address her personal care needs. Compared to a prior UAS, the patient had a large decline in ADL functional ability. 

At issue is the medical necessity of 56 hours per week of personal care aide. 

The requested health service of Personal Care Aide increase to 56 hours per week is not medically necessary for this patient.
The patient has functional limitations and requires assistance with most ADL's and IADL's as documented by the UAS. The notes state that the patient requests additional hours to assist with IADL's and transfers; however, these needs are accounted for in the plan's tasking tool, which recommended 29.7 hours per week. The patient is approved for 42 hours per week, which is already more than the recommendation. This should also help to account for the fecal incontinence that has developed since the UAS was last done. There is no clear documentation that the patient has any unmet personal care needs. Therefore, there is insufficient evidence that the requested increase in hours is medically necessary for the patient.