Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis/ 
Treatment: Personal Care Aide - Level 2: 80.5 Hours/Week, 11.5 Hours times 7 Days/ 
The insurer denied: Personal Care Aide - Level 2: 80.5 Hours/Week, 11.5 Hours times 7 Days/ 
The denial is upheld. 

The patient is an adult male with multiple sclerosis. He is requesting an increase in personal care aide hours up to 80.5 hours per week or 11.5 hours times 7 days. The 
patient has been approved for 8 hours times 5 days and 11.5 hours times 2 days, or 63 hours per week. 
Four months ago, a Uniform Assessment System was performed. It reported that the patient has a diagnosis of multiple sclerosis, depression, vitamin deficiency, obsessive compulsive disorder (OCD), constipation with fecal smearing, tremor, and difficulty walking. It further noted that the patient's needs/impairment include (but are not limited to): 
1. Modified independence of decision-making with activities of daily living (ADL). 
2. Problem with short-term memory with "okay" procedural memory. 
3. Maximal assistance is needed with bathing, lower extremity dressing, and toilet transfer. 
4. Extensive assistance is needed for upper extremity dressing and toilet use. 
Compared with a Uniform Assessment System from last year, the patient now has: 
1. A short-term memory problem. 
2. Limited assistance needs (from only supervision) with locomotion. 
3. Maximal (from extensive) toilet transfer. 
4. A need for supervision (from limited assistance) with eating. 
5. Bowel and bladder continence issues/needs were unchanged. 
6. The patient's primary mode of indoor locomotion is a wheelchair or a scooter (unchanged). 
Per the health plan, the "plan of care is adequate for your care needs. Based on a review of the assessment and your ongoing need for personal care, your needs can be met with the following services: 7 hours and 30 minutes per day, 5 days per week, and 11 hours and 30 minutes per day, 2 days per week of Level 2 Personal Care Assistance Services. This service will remain the same."
The Final Adverse Determination Denial noted that the patient was approved for up to 63 hours per week (5 days times 8 hours, and 2 days times 11.5 hours). The request for up to 80.5 hours per week was denied. 

The requested health service is not medically necessary. 

As noted, the review of records indicates there is a decline in the patient's function compared to the assessment last year as noted above. This warrants an increase in hours as approved by the health plan, up to 63 hours a week. The issue of further extending personal care assistance up to 80.5 hours per week is not supported by unchanged needs for the bladder and urinary incontinence. It is unclear from the records if the patient needs intermittent urinary catheterization or has an indwelling catheter to address the nighttime urination issues. Based on the review of records, the bowel incontinence is likely related to multiple sclerosis (MS)-related constipation and is, therefore, likely, an overflow incontinence that can be addressed with adult diapers (if need be). The need for enemas for constipation is not continuous but rather intermittent, per the patient's primary care physician, and can be addressed during daytime assistance. At this time, there is also no mention of a recent urinary tract infection or bed sores that would warrant additional hours (beyond the approved 63 hours per week). The patient's 
primary care indicated that the patient has a cognitive impairment and needs help with decision-making. The assessment of 4 months ago indicates that the patient only needs modified independence of decision-making with activities of daily living (ADL). The other concerns brought up by the Providers are not clearly directly related to nighttime personal assistance. The occurrence of bed sores, urinary tract infection, and the need for nighttime medications are factors that should be considered in the future for additional assistance hours.