Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis
Treatment: Personal care services (PCS) 84 hours per week
The insurer denied Personal care services (PCS) 84 hours per week.
The determination is overturned.

The patient is a female with a medical history notable for multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), diabetes, and left eye blindness. The patient was approved for 43 hours per week of personal care services. The patient and her care team requested an increase to 12 hours per day, 7 days per week for a total of 84 hours per week. The request was partially approved by the health plan, who approved a total of 56 hours per week.
The patient's neurologist states that the patient has diagnoses of multiple sclerosis, Graves disease, type 2 diabetes, COPD, blindness in the left eye, and multiple spinal surgeries. The patient is unable to walk more than 10 feet without assistance and uses a powered wheelchair for greater distances. The patient requires assistance with activities of daily living including bathing, dressing, hygiene, and toileting. She lives in a building with limited handicap accessibility which allows neither a walker nor a wheelchair to pass through the bathroom door. The patient also requires the use of diapers and requires assistance with changes. The physician notes that the patient should have no less than 12 hours per day 7 days per week of personal care assistance to meet her personal care needs.
A Uniform Assessment System (UAS) was completed. The patient lives in a one-bedroom apartment and currently lives alone. She was alert and oriented and able to direct her own care. For her instrumental activities of daily living, the patient requires maximal assistance or total dependence for nearly all. For her activities of daily living, the patient required extensive assistance for bathing, dressing upper body, and dressing lower body. She required limited assistance for toilet use. She was identified to be independent for all other activities of daily living. The narrative of functional status states that the patient's personal care aide assists with transfers, toileting, and diaper changes. The patient is incontinent of both urine and stool with no control present and requires four to six diaper changes per day. The patient had one fall in the previous 90 days. There was no pressure ulcer present. At issue is the medical necessity of the requested personal care services (PCS) 84 hours per week.

The requested health service of PCS 84 hours per week is medically necessary for the patient.
The description by the physician of the patient's personal care needs suggests that her level of reliance on her personal care assistant is greater than indicated by the UAS. The narrative within the assessment also describes that she needs assistance with transfers, toileting, and diaper changes, again suggesting that the amount of assistance that she requires may be greater than initially indicated. Because her care needs can be expected to be continuous and unscheduled throughout the day, the requested increased to 12 hours per day is medically necessary and reasonable for the patient. This will allow for adequate assistance with all activities throughout the day, including transfers, toilet and, eating, and dressing. Failure to provide for the patient's personal care needs could result in injury and or infection.