Appeal type: Medical necessity
Decision: Overturned



Diagnosis: Incontinence/Urinary/Bladder Control
Treatment: Personal Care Services Level 2 (12 hrs. per day, 7 days per week, total 84 hrs. per week)

The health plan denied: Personal Care Services Level 2 (12 hrs. per day, 7 days per week, total 84 hrs. per week)
The determination is: Overturned.

The patient is a male with medical history notable for dementia, rheumatoid arthritis, cancer, incontinence, and ambulatory dysfunction. The patient is approved for 8 hours per day, 7 days per week (56 hours [hrs] per week) of level 2 personal care services. The patient and his care team requested an increase to 12 hours per day, 7 days per week (84 hours per week).
The patient's daughter-in-law provided a letter of support for this appeal. The letter states that the patient was hospitalized with weakness and a urinary tract infection. He was in a rehabilitation facility as of the time of the letter writing. He requires assistance with walking due to unsteadiness and fall risk. He will therefore require human assistance with toileting and changing diapers. The family member is requesting additional assistance to help with these tasks.
The patient's oncologist provided a letter of support for this appeal. The patient was previously treated for prostate cancer and is now on chemotherapy for skin cancer. He has become "increasingly weak in the preceding month and needs full hands-on assistance with various activities of daily living (ADL)." The physician recommends assistance with transfers, ambulation, and toileting, which will occur throughout the day. Therefore, the physician recommends "care throughout his waking hours."
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person. The patient lives in a 1-bedroom apartment with his spouse who is "able to provide very limited assistance due to her own health conditions." The patient was disoriented with moderately impaired cognition. He requires maximal assistance or total dependence for all instrumental activities of daily living (IADL). For his ADL's, he requires maximal assistance for bathing, dressing his lower body, walking, locomotion, toilet transfer, and toilet use. He requires extensive assistance for hygiene and dressing his upper body. He requires limited assistance for bed mobility and eating. He is frequently incontinent of urine and continent of stool. Compared to a prior UAS, he showed a decline in functional and cognitive status.
At issue is the medical necessity of Personal Care Services Level 2 (12 hrs per day, 7 days per week, total 84 hrs per week).
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Personal Care Services Level 2 (12 hrs per day, 7 days per week, total 84 hrs per week) is medically necessary for this patient.
The patient is completely reliant on others for assistance with transfers, ambulation, and toileting. He is incontinent of urine and unable to manage his own incontinence care. His personal care needs are expected to be continuous and unscheduled throughout the day. The patient cannot be reasonably expected to receive toileting and incontinence care for only 8 hours per day. The requested increase in personal care hours is reasonable and medically necessary for the patient. Failure to address his personal care needs could result in skin breakdown and/or infection.