Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Retina Problem
Treatment: Personal Care Aide (PCA) Level 2: 8 hours per day - 7 days a week - a total of 56 hours per week
The health plan denied: Personal Care Aide (PCA) Level 2: 8 hours per day - 7 days a week - a total of 56 hours per week
The determination is: Overturned

This is a case review for a female with medical history notable for retinitis pigmentosa. The patient is approved for 8 hours per day, 6 days per week, and 5 hours per day, 1 day per week (53 hours per week) of level 2 personal care aide services. The patient and her care team requested an increase to 8 hours per day, 7 days per week (56 hours per week).
The patient's physician provided a letter of support for this appeal. The patient has a medical history significant for lupus, chronic kidney disease, retinitis pigmentosa, vascular dementia, and depression. The letter states that the patient has had recurrent falls which have resulted in hospital visits almost monthly. These falls are largely attributed to her vision issues resulting in near blindness. She has difficulties with ambulation due to lupus. The physician requests additional care time to meet her personal care needs.
The patient's sister (and power of attorney) wrote a letter of support for this appeal. The letter requests additional aide hours for Sundays to help her condition. The health plan previously stated that the patient has informal support from family on Sundays, and the patient's sister states that this is incorrect; she is alone on Sundays when an aide is not present. The patient cannot shower, cook, eat, or take medication without assistance. She states that if the patient requires daily assistance for these tasks, the plan cannot skip coverage for Sunday. The patient had three hospital visits over the prior two months related to falls.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person. The patient lives alone in an apartment. The patient was only partially oriented to time; she is self-directing but forgetful. Her recall was 0/3 at five minutes, and her procedural memory is not intact. For her instrumental activities of daily living (IADL), she requires maximal assistance or total dependence for all. For her activities of daily living (ADL), she requires extensive or maximal assistance for all (with the exception of eating). She is frequently incontinent of urine and infrequently incontinent of stool. She uses underpads and pullups for incontinence care. Notably, she requires maximal assistance for toileting and dressing her lower body.
At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 8 hours per day - 7 days a week - a total of 56 hours per week.
The health plan's determination of medical necessity is overturned in whole.
The requested health service of Personal Care Aide (PCA) Level 2: 8 hours per day - 7 days a week - a total of 56 hours per week is medically necessary for this patient.
The patient requires maximal assistance for toileting and transfers. She is incontinent and unable to perform her own diaper changes. She has had frequent falls which are evidence of insufficient support when attempting personal care tasks without an aide present. The increase in hours is medically necessary and reasonable. She can be reasonably expected to require the same amount of assistance on Sundays as she does for other days of the week.