Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebrovascular Accident (CVA). 
Treatment: Level 2 personal care services, per 15 minutes increase to 112 hours per week. 

The insurer denied level 2 personal care services, per 15 minutes increase to 112 hours per week. 
The determination is upheld. 

The patient has a medical history notable for a cerebrovascular accident (CVA) with subsequent left sided hemiplegia, gait disorder, right above the knee amputation, coronary artery disease, type 2 diabetes, chronic obstructive pulmonary disease (COPD), and urinary incontinence. The patient was receiving 49 hours per week of level 2 personal care services. His care team requested an increase to 112 hours per week, and this request was denied by the insurance plan. This denial is the subject under review. No letters of medical necessity or physician office notes were provided in this appeal.
A Uniform Assessment System (UAS) was completed and was available for review. A prior assessment was available for comparison. The most recent review occurred in the setting of 3 hospitalizations over the prior month. He was admitted twice for uncontrolled pain due to bone cancer that has metastasized, and once with chest pain. From a cognitive standpoint, he is alert and oriented with episodes of forgetfulness (including forgetting to take medication). Five-minute recall is 1/3. His daughter is available to help with finances as he cannot pay his own bills. He is currently receiving 49 hours per week of consumer directed personal care. The assessment reports strong family support and that he is not left home alone for a long time. His aide usually stays until 4:00 PM at which point he may be alone depending on informal family member support. Adult day healthcare services were discussed, but the patient and his family were not interested. 

On functional evaluation, the patient was found to have total dependence for meal preparation and ordinary housework. He requires extensive assistance for managing medications. For activities of daily living, he requires maximal (max) assistance for bathing, dressing lower body, and toilet transfer. He requires extensive assistance for hygiene, dressing upper body, toilet use, and bed mobility. He requires total dependence for locomotion, for which he is dependent on a wheelchair/scooter. Per the evaluation: "Member is wheelchair bound, non-ambulatory due to right above the knee amputation, member needs max assistance with transferring, getting in and out of the tub/washing, and putting on his lower garments." He is occasionally incontinent of urine (less than daily) and uses pads at times. He is continent of stool. He reports falling frequently in the last month; he has been trying to transfer to the wheelchair to use the bathroom but is very weak and falls down and has had to call an Emergency Medical Technician (EMT) to help him get up (no one was home during these events). He suffered bruising but no serious injuries. When compared to his prior assessment, his level of assistance required for activities of daily living (ADLs) and instrumental activities of daily living (IADL) was essentially unchanged. 

A tasking tool was provided with the assessment which recommended 42 hours per week of personal care services to meet his personal care needs, which represented an increase of 1 hour per week over the previous recommendation of 41 hours per week. At issue is the medical necessity of level 2 personal care services, per 15 minutes increase to 112 hours per week. 

The requested health service/treatment of level 2 personal care services, per 15 minutes increase to 112 hours per week does not have established medically necessary for this patient. 

Only the Uniform Assessment System (UAS) was provided in this appeal. The UAS demonstrates that the patient has significant functional limitations, but he does receive 7 hours per day of consumer directed personal assistance. The UAS was unchanged from one year ago from a functional standpoint. His total weekly hour amount is greater than that recommended by the task tool. 

It does appear that he has had some clinical deterioration over the past month and worsening pain, but there is no established medical necessity for unmet personal care needs that would require an increase in his personal care hours.