Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide Level 2: 12 hrs per day-7 days per week - a total of 84 hrs per week
The health plan denied: Personal Care Aide Level 2: 12 hrs per day-7 days per week - a total of 84 hrs per week
The determination is: Overturned

The patient is a female with medical history notable for dementia, incontinence, and arthritis. The patient is approved for 9 hours (hrs) per day, 7 days per week (63 hours per week) of level 2 personal care services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient requires total assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) including toileting and transfers. She has an unsteady gait and has had recurrent falls when attempting to ambulate independently resulting in rib fracture. The physician feels that additional personal care is necessary for the patient to have adequate assistance with her personal care activities.
The patient's daughter provided a letter of support for this appeal. The letter states that the patient is doing well at home, but her dementia is advancing. The patient's child is providing additional support when a caregiver is not there, but it is becoming more challenging to provide this informal support. The letter states that the additional hours would allow the patient to receive the care needed to remain in her own home. The patient's daughter also disagrees with the assessment that the patient can direct her own care. She is reliant on others for all personal care activities and cannot remember to direct her own care. The additional three hours would be used to address an evening meal, evening hygiene, and oversight/cueing for final medication dosages. She will not take care of those things without an assistant present, even if they are prepared for her because she does not remember.
A Uniform Assessment System (UAS) was available for review. The assessment was conducted in-person. The patient lives alone in her apartment. She was alert and oriented to person and place only. Her recall was 1/3 at five minutes and she cannot perform a procedural task. Her cognition was noted to fluctuate, and she frequently gets confused. For her IADLs, she requires total dependence for meal preparation, housework, and shopping. She requires maximal assistance for finances, medications, and transportation. For her ADLs, she requires maximal assistance for bathing, dressing, hygiene, and toilet transfer/use. She requires extensive assistance for walking, locomotion, and bed mobility. She is frequently incontinent of urine and continent of stool. She uses pull-ups for incontinence care. A task tool recommended 7 hours per day to address her personal care needs. Her functional and cognitive evaluations did not change significantly from a prior UAS.
At issue is the medical necessity of Personal Care Aide Level 2: 12 hrs per day-7 days per week - a total of 84 hrs per week.
The health plan's determination of medical necessity is overturned in whole.The requested health service of Personal Care Aide Level 2: 12 hrs per day-7 days per week - a total of 84 hrs per week is medically necessary for this patient.
The patient has dementia, mobility problems, and incontinence. She is not able to completely direct her own care. Her personal care needs are not easily scheduled during a personal care shift due to the fact that they are expected to be continuous and unscheduled by nature. Her physician and her daughter attested to the benefit of additional personal care hours. Her falls with rib fracture while attempting to complete personal care tasks without assistance are evidence of unmet personal care needs.