Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Incontinence. 
Treatment: Personal Care Aide Level 2 Live-in per diem; 1 day a total of 7 days per week. 

The insurer denied: Personal Care Aide Level 2 Live-in per diem; 1 day a total of 7 days per week. 
The denial is overturned. 

The patient is a female with medical history notable for spinal stenosis, peripheral neuropathy, atrial fibrillation, and urinary incontinence. She is currently receiving 7 hours per day, 7 days per week for a total of 49 hours per week of personal care assistance services. The patient has been paying for a private live-in caregiver but is no longer able to do so. The patient and her care team requested an increase in covered services to 24 hours per day (live-in) personal care. This request was denied by the health plan and is the subject under review.

A Uniform Assessment System (UAS) was completed and was the most recent assessment available for review. The patient was found to be alert and oriented times three with periods of forgetfulness. Her five-minute recall was 2/3. She is able to communicate her needs. From a functional standpoint, she requires total dependence for housework. She requires maximal assistance for meal preparation, managing finances, managing medications, and shopping. For her activities of daily living (ADL's), she requires total dependence for locomotion. She requires maximal assistance for bathing, dressing lower body, walking, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She is only able to take 1-2 steps with significant weight bearing assistance, otherwise she is wheelchair bound. She is frequently incontinent of urine (daily) and occasionally incontinent of stool. She wears pull ups with assistance required for changing. Compared with a prior UAS, she showed a decline in functional status on several ADL's. A task tool associated with the most recent assessment recommended 49 hours per week to address her need for personal care services.

The requested Personal Care Aide Level 2 Live-in per diem; 1 day a total of 7 days per week is medically necessary for this patient. The patient has significant personal care needs as demonstrated by the UAS. She is not able to perform any ADL's or instrumental activities of daily living (IADL)'s independently. Most concerning is her incontinence and inability to change her own incontinence products. The patient's current live-in aide gave a detailed log of the daily hours spent with the patient which demonstrates the need for personal care services throughout the day and night. She should not be expected to go the majority of the day and night without an aide to help with managing toileting and incontinence. She has a history of skin breakdown and infection, both of which would be likely to recur if she were not given the proper level of support. The tasking tool can help serve as a minimum for hours needed to support a patient's personal care needs, but it is not sufficient when the patient has frequent and unscheduled personal care needs such as toileting and incontinence care. These cannot be scheduled and thus she requires continuous assistance. Because she does not require bed positioning, it is reasonable to expect a live-in aide to be able to get 5 hours of uninterrupted sleep at night.