Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Memory loss from a brain tumor
Treatment: Live-in 7 days/week of consumer directed personal assistance services
The insurer denied live-in 7 days/week of consumer directed personal assistance services.
The determination is upheld.

The patient is a female with a medical history notable for memory loss from a brain tumor. The patient is approved for 21 hours/week of consumer directed personal assistance services (CDPAS). The patient and her care team requested an increase to live-in personal care, 7 days/week, and this request was denied by the health plan.

The patient's physical therapist provided a letter for this appeal. The letter states that the patient has been receiving therapy for vertigo, dizziness, and balance impairment which started after surgical resection of a meningioma. The patient uses a cane or a walker for balance assistance while walking, but still remains a fall risk with her symptoms. The patient lives alone and the therapist reports that she would benefit from assistance with transfers, walking, and other activities of daily living (ADLs).

The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient is cognitively impaired and has been declining. She requires assistance with toileting and transfers. She has had multiple falls due to dizziness.

The requesting physician provided a letter of support for this appeal. The letter states that the patient has urinary incontinence and needs assistance with walking, transfers, toileting, feeding, and bathing. The physician recommends 9-10 hours/day to address her personal care needs.

A Uniform Assessment System (UAS) was completed. The summary of the assessment was provided. The patient lives with her husband in an apartment. She receives frequent assistance from a friend. She was alert and oriented with short term and procedural memory intact. For her instrumental activities of daily living (IADLs), she requires some assistance to complete tasks such as shopping and transportation. For her ADLs, she is able to toilet, transfer, and eat independently. She showers every 2 days and uses some non-weightbearing assistance with getting into and out of the tub. She has rare episodes of urinary urge incontinence (none in the prior 3 days). There were no falls in the previous 90 days. She has episodes of dizziness which make ambulation difficult. A task tool associated with the assessment recommended 11.56 hours/week to address her personal care needs. At issue is the medical necessity of live-in 7 days/week of CDPAS.

The requested health service of live-in 7 days/week of CDPAS has not been clearly demonstrated to be medically necessary for this patient.

The patient requires some assistance with IADLs and is mostly independent for ADLs. Her limitations are driven by bouts of dizziness which have occurred in the setting of a recent benign brain tumor resection. Her functional assessment recommends 11.56 hours/week to address her needs, and the health plan has granted 21 hours/week. Her urinary incontinence is infrequent and she is able to toilet independently. She does not carry any medical conditions or functional deficits that would qualify for live-in personal care. The requested service has therefore not been demonstrated to be medically necessary for the patient.