Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure/CHF
Treatment: Increase in Consumer Directed Personal Care Assistance from 34 hours per week to Consumer Directed Personal Care Assistance, 10 hours per day 7 days per week, total of 70 hours per week.
The health plan denied the requested increase in Consumer Directed Personal Care Assistance from 34 hours per week to Consumer Directed Personal Care Assistance, 10 hours per day 7 days per week, total of 70 hours per week.
The health plan's determination is overturned.

This is a case review for a female with medical history notable for heart failure. The patient is approved for 34 hours per week of Consumer Directed Personal Care assistance. The patient and her care team requested an increase to 10 hours per day, 7 days per week (70 hours per week).

A letter of support for this appeal was provided by the patient's physician. The letter states that the patient needs assistance with dressing, showering, meals, shopping, toilet transfers, and toilet use. The physician states that due to her congestive heart failure, she requires frequent assistance to the commode and changes of soiled clothing. The letter states that she requires additional hours to meet her needs.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented times three. Her recall was 1/3 at five minutes. Procedural memory was impaired. For her instrumental activities of daily living (IADLs), she required maximal assistance for meal preparation, housework, finances, stairs, and shopping. For her activities of daily living (ADLs), she required extensive assistance for bathing, hygiene, dressing upper body, and dressing lower body. She required limited assistance for toilet transfer and toilet use. She required supervision only for walking, locomotion, and eating. She is frequently incontinent of urine and continent of stool. She requires changing about 4 times per day due to incontinence. A task tool associated with the assessment recommended 26.5 hours per week to address her personal care needs.

At issue is the medical necessity for the requested health service/treatment of an increase in Consumer Directed Personal Care Assistance from 34 hours per week to Consumer Directed Personal Care Assistance, 10 hours per day 7 days per week, total of 70 hours per week.

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

The requested health service of increase in Consumer Directed Personal Care Assistance from 34 hours per week to Consumer Directed Personal Care Assistance, 10 hours per day 7 days per week, total of 70 hours per week is medically necessary for this patient.
The patient has functional limitations as outlined in the UAS. However, the letter from the patient's physician (which is 6 months more up-to-date than the UAS) states that her hours are not adequate for her needs. Her task tool only allows for toileting twice per day, and the physician states she requires much more than this. There is also no time allotted to incontinence care in the task tool. Due to the physician's attestation of a decline in her functional status and requirement for additional hours, it is medically necessary to allow a modest increase to meet her needs.