Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical, thoracic, and lumbar spinal disease
Treatment: Consumer direct personal care aide-168 hours per week
The insurer denied Consumer direct personal care aide-168 hours per week.
The determination is overturned.

The patient has a medical history notable for cervical, thoracic, and lumbar spinal disease, chronic obstructive pulmonary disease, and major depression. The patient was receiving 50 hours per week of consumer directed personal care aide services. The patient's care team requested an increase to 168 hours per week of consumer directed services. The health plan denied this request partially, but did increase the hours to 56 hours per week.
The patient's primary care physician provided a letter of support for this appeal. The physician states that the patient's "clinical, functional, and psychological status has been deteriorating." He identifies leg pain causing spasm as a driver of this functional decline. The patient also has "a very unsteady gait and a history of multiple falls. In addition, his depression/anxiety has worsened." He identifies specifically that the patient needs help with bathing, grooming, and meal preparation.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented, and showed forgetfulness at times but was able to make his needs known. He had symptoms of depression within the 3 days prior to the evaluation. On functional status evaluation, he requires maximal assistance for meal preparation and housework. He requires extensive assistance for managing finances and limited assistance managing medications. For activities of daily living, he requires maximal assistance for bathing. He requires extensive assistance for dressing upper/lower body, walking, locomotion, toilet transfer, toilet use, and bed mobility. He requires limited assistance for personal hygiene. The notes state that he is "unable to walk or stand without human assistance...The patient requires extensive assistance with positioning changing and all transfers. He is not able to change his position from lying down to sitting without help...Due to physical decline, the patient is not able to complete his activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) without assistance." He was occasionally incontinent of urine at night. He was continent of stool.
A subsequent UAS was repeated to update the prior assessment. On functional evaluation, he was noted to require similar assistance levels for IADLs. On ADLs, he showed worsening performance; he now requires maximal assistance for dressing lower body, walking, locomotion, toilet transfer, and toilet use. He developed frequent incontinence in the interim due to a diagnosis of spinal stenosis. He wears pull-ups and changes 3-4x per day. He is still continent of bowels. A tasking tool associated with the assessment recommended 37.25 hours per week to address his ADL/IADL needs.
At issue is the medical necessity of consumer direct personal care aide-168 hours per week.

The requested health service/treatment of consumer direct personal care aide-168 hours per week is medically necessary for this patient.
This patient has significant functional needs for his ADLs and IADLs. Over the course of the year, he has demonstrated a decline in ADL function. He now requires maximal assistance for most activities, including toileting and dressing lower body. This is compounded by his development of multiple daily episodes of urinary incontinence. The combination of the inability to care for his toileting needs and incontinence is very difficult to care for on limited personal care hours. The tasking tool is useful for determining necessary hours for episodic care such as with IADLs, but is not as applicable once the patient develops unscheduled health needs like incontinence care. It is not reasonable to expect the patient to schedule his toileting needs around his personal care hours given that he has incontinence. If he were to only get limited hours, he would be required to lay in a soiled pull-up until his aide could help. With only one third of the hours of the week, this is not a reasonable expectation to cover this patient's medical needs.