Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis. 
Treatment: increase in personal care services from 40 hours to 24 hrs per day (live in). 
The health plan denied: increase in personal care services from 40 hours to 24 hrs per day (live in). 
The determination is overturned. 

This is a case review for a female with medical history notable for degenerative joint disease of the spine. The patient is approved for 40 hours per week of personal care services. The patient and her care team requested an increase to 24-Hour per day (live-in) personal care, and this request was denied by the health plan. This denial is the subject under review. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient has spinal stenosis, osteoporosis, neuropathy of all extremities, and progressive weakness with sensory loss. Because of these functional limitations, the patient is mostly wheelchair-bound and bed bound. She is unable to complete transfers or ambulation without assistance from another person. 
Office visit notes from the treating physician were provided for review. The patient is only able to get up with assistance. She walks slowly with a walker and has gait imbalance. She has episodic urine and bowel incontinence and wears diapers for incontinence care. She requires assistance from her caregiver for diaper changes. The physician assessment states that the patient is fully dependent on others for her care needs and is at high risk of deterioration, fall, and/or death if left unattended. 
A Uniform Assessment System (UAS) was completed. The patient lives in a private house with her son. The patient was alert and oriented but forgetful. Recall was zero out of three at 5 minutes. For her instrumental activities of daily living, the patient requires total dependence for housework. She requires maximum assistance for transportation, shopping, stairs, finances, and meal preparation. She requires extensive assistance for medications and phone use. For her activities of daily living, the patient requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She requires hands-on assistance for transfers and ambulation. She is frequently incontinent of urine and stool and uses Pull-Ups for incontinence care. There was no fall in the previous 90 days. There was no pressure ulcer present at the time of evaluation.
At issue is the medical necessity of an increase in personal care services from 40 hours to 24 hours per day (live in). 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service of an increase in personal care services from 40 hours to 24 hours per day (live in) is medically necessary for this patient. 
The patient has significant functional limitations as outlined in the assessment and in the physician letters. The patient requires hands-on caregiver assistance for all activities of daily living including ambulation, transfers, and toileting. Her care needs can be expected to be continuous and unscheduled throughout the day and occasionally at night as well. Furthermore, she has incontinence of bowel and bladder and requires assistance with diaper changes as needed for episodes of incontinence. By definition, these needs will be unscheduled. Therefore, the requested increase to 24 hour live in personal care is medically necessary for the patient. Failure to provide for the patient's personal care needs could result in skin breakdown, injury, and/or infection.