Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unsteady gait
Treatment: increase in personal care services from 35 hours to 56 hours per week
The insurer denied increase in personal care services from 35 hours to 56 hours per week.
The determination is overturned.

This is a male patient with a history of chronic sinus thrombosis, pulmonary thrombosis, history of stroke, hypertension, coronary artery disease, urinary incontinence, and unsteady gait. The patient was previously approved for personal care assistance (PCA) services for 35 hours per week. The patient and his care team are requesting 56 hours per week of PCA services.
An in-person Uniform Assessment System (UAS) was completed. The patient was assessed at total dependence for the task of ordinary housework; maximal assistance for meal preparation and shopping; extensive assistance for managing finances, managing medications, stairs, transportation, and bathing; limited assistance for dressing lower body and toilet use; setup help only for phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, bed mobility, and eating. A tasking tool was used to determine that he requires 35.42 hours of aide service per week.
The patient's primary care physician (PCP) provided a letter of support. His PCP is requesting an increase in home care services due to deterioration in his condition. His PCP states that he needs total assistance with activities of daily living (ADLs) of bathing, dressing, eating, walking, transferring from bed to chair, and toileting. His PCP states that he uses the commode every 2 hours, and he needs to be cleaned and changed frequently during the night due to incontinence.
The patient's daughter states that he cannot safely go to the bathroom, get dressed, or walk around his apartment after his aid leaves. His daughter states she is his only local support person and is unable to provide an adequate level of support due to her personal family circumstances and her father's increasing need for assistance. At issue is an increase in personal care services from 35 hours to 56 hours.

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, an increase in personal care services from 35 hours to 56 hours per week is medically necessary.
The patient's PCP states that he requires total assistance with walking and toilet use. The patient's daughter and community advocate also state that he requires assistance with walking and toilet use. There is documentation in the UAS of the patient requiring limited assistance with the task of toilet use and setup help only with tasks of walking, locomotion, and transfer toilet. The UAS underestimated the patient's needs and is not consistent with the attending physician's recommendations and statement of medical necessity of increased PCA services. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. Although the patient lives with his spouse and therefore, has informal support, the plan cannot assume that the informal support person can provide all needed care outside of the approved PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).