Appeal type: Medical necessity
Decision: Overturned

Diagnosis: end stage renal disease on dialysis, paraplegia due to spina bifida, asthma, diabetes, and hypertension.
Treatment: Increase Personal Care Services From 40 Hours A week To 12 hours a day, 7 days a week for 84 Hours A Week.
The insurer denied the Increase Personal Care Services From 40 Hours A week To 12 hours a day, 7 days a week for 84 Hours A Week.
The denial is overturned. 

The patient is a male with conditions including end stage renal disease on dialysis, paraplegia due to spina bifida, asthma, diabetes, and hypertension.  He lives alone.  He is unable stand for prolonged periods.  He is appealing denial of PCS (personal care services) 12 hours per day, total of 84 hours per week.  He has been approved for PCS (personal care services) 8 hours per day, total of 40 hours per week.

The patient's UAS (Uniform Assessment System) evaluation performed shows independent cognition and functional status: total dependence with housework; maximal assistance with shopping; extensive assistance with meal preparation, stairs, transportation, bathing, and lower body dressing; limited assistance with managing finances and medications, personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with phone use, bed mobility and eating.  Total hours of physical activity is less than one hour.  His DME (durable medical equipment) includes peer wheelchair, pull up, shower chair, commode, and toilet seat rail.  He is frequently incontinent of bladder and uses a condom catheter. He is occasionally incontinent of bowel.  Compared to UAS (Uniform Assessment System) evaluation performed, the patient requires more assistance with managing medications, shopping, locomotion, and toileting.  Physical activity level was 1 to 2 hours.

An appeal letter from the patient's provider notes that the patient is wheelchair-bound and requires assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.  An appeal statement from NY (New York) Ombudsprogram notes that the current PCS (personal care services) leaves the patient without an aide for 16 hours.  It notes that increased hours are needed because of multiple comorbid deteriorating conditions.

Yes, the Increase in Personal Care Services from 40 Hours a week to 12 hours a day, 7 days a week, for a total of 84 hours a week is medically necessary.
Medically necessary services are those which are:
1) safe 
2) effective
3) generally accepted national standard of medical practice 
4) not provided primarily for convenience of the patient or the practitioner 
5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary, because it is consistent with generally accepted national standard of medical practice.

Personal Care Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.

This patient is homebound.  This patient has multiple chronic conditions, including end stage renal disease on dialysis, and he is wheelchair bound.  He lives alone.  He is appealing denial of increase PCS (personal care services) to 84 hours per week.  He has been approved for 40 hours per week.

The patient's UAS (Uniform Assessment System) evaluation performed shows the patient needs assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living) except phone use, bed mobility and eating.  Compared to the UAS (Uniform Assessment System) evaluation performed more recently, the patient requires more assistance with managing medications, shopping, locomotion, and toileting.  In addition, the patient renal disease and mobility declined.  The patient is incontinent of bladder and bowel.  Appeal statements note the patient needs more assistance due to deterioration in functional states and being wheelchair bound.  Documentation shows that there has been a significant decline in the patient's functional status.  He now requires more assistance with locomotion and toileting.  The currently approved PCS (personal care services) 40 hours per week, leaves the patient for a significant amount of time without assistance. These hours are insufficient to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living).  The proposed increase in PCS (personal care services) to 84 hours per week is medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.