Appeal type: Medical necessity
Decision: Overturned

Diagnosis: polyarthropathy.
Treatment: Personal Care Aide (PCA) Level II & Consumer Directed Personal Assistance Services (CDPAS): 84 Hours per Week - 12 Hours per Day / 7 Days per Week .
The insurer denied: Personal Care Aide (PCA) Level II & Consumer Directed Personal Assistance Services (CDPAS): 84 Hours per Week - 12 Hours per Day / 7 Days per Week. 
The denial is: Overturned.

The patient is a female with medical history notable for urinary incontinence, gait and mobility abnormalities with falls, neuropathy, and inflammatory polyarthropathy. The patient was approved for 6 hours per day, 7 days per week (42 hours per week) of consumer directed personal assistance services (CDPAS). The patient and her care team requested an increase to 84 hours per week CDPAS (12 hours per day, 7 days per week). The health plan partially approved this request by increasing to 49 hours per week but denied the request for 84 hours. This denial is the subject under review. A Uniform Assessment System (UAS) was completed and was available for review. Cognition was found to be intact and independent in decision making. On functional evaluation, she requires total dependence for meal preparation and housework. She requires maximal assistance for managing finances and medications, shopping, transportation, and equipment management. For her activities of daily living (ADL's), she requires maximal assistance for bathing, dressing upper/lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene. She requires limited assistance for bed mobility and eating. The assessment states: "Member ambulates very slowly with her rollator walker, CDPAS aide walks behind her as she is unsteady and has fallen backwards multiple times in the past...Member requires assistance walking to the bathroom and sitting on and off the toilet." She is frequently incontinent of urine (daily) and uses pull-ups. She is infrequently incontinent of stool (she does have episodes although there were none in the 3 days prior to the evaluation). An accompanying tasking tool recommended 49 hours per week of personal care services to address her needs.

The health plan's determination is overturned.

The requested Personal Care Aide (PCA) Level II & Consumer Directed Personal Assistance Services (CDPAS): 84 Hours per Week - 12 Hours per Day / 7 Days per Week is medically necessary for this patient.
The patient has clearly demonstrated need for assistance with ADL's and Instrumental activities of daily living (IADLs) as outlined by her physician documentation and the UAS tool. She needs to have an aide present for any ambulating or toileting needs, as well as others as previously outlined. Due to the unscheduled nature of toileting needs and their frequency spread throughout the day, it is difficult to use a tasking tool to determine the exact number of hours that an aide is truly needed. Furthermore, her urinary incontinence will provide additional unscheduled needs throughout the day. The health plan submitted this denial in part due to safety monitoring not being a function of personal care assistance. While this is correct, the assistant is not being used as a safety monitor in this case; the aide is actively participating in helping her with ADL's and IADL's, which by definition is a personal care function. Failure to provide this support would not be meeting her basic needs and could be expected to lead to accidents or further deterioration of her functional status.