Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Joint pain/arthritis
Treatment: Personal Care Aide 50 Hours/week; Consumer Directed; 1
Client
The health plan denied the Personal Care Aide 50 Hours/week; Consumer Directed; 1
Client.
The reviewer has upheld in whole the health plan's determination. 

This is a case review for an adult female with medical history notable for neck pain, hip and leg pain, arthritis, and anxiety. The patient was receiving 50 hours per week of consumer directed personal care aide services. The health care plan reduced her hours to 14 hours per week. The patient and her care team appealed this reduction, and the appeal was partially denied. The hours were reduced to 35 hours per week. The denial of return to the full 50 hours per week is the subject under review.
The patient's orthopedist provided a letter of medical necessity. The letter outlines the patient's history of having an anterior cervical fusion earlier this year which was complicated by vocal cord paralysis. She has an upcoming right total knee replacement. The physician expressed concern that the patient's combination of neck and lower extremity orthopedic issues would limit her ability to care for herself. He also describes the possibility of a hip procedure in the future. He states that "the aide support is critical in her ability to complete activities of daily living."
A letter of support was provided from a physician assistant in an internal medicine office where the patient is treated. The letter reviews the patient's medical history and that she would benefit from aide hours to help with activities of daily living (ADL's). The most recent office visit note from the physician assistant described workup for peripheral edema and chronic cough; ADLs were not referenced at that time.
An emergency department visit note was provided for review. They describe a "moderate voice deficit secondary to recurrent laryngeal nerve (RLN) damage" and recommend ongoing outpatient speech therapy.
A Uniform Assessment System (UAS) was completed. From a functional status standpoint, she requires extensive assistance for housework, stairs, shopping, and transportation. She requires limited assistance for meal preparation. For activities of daily living (ADL's), she is independent in all domains. She walks without an assistive device. She is infrequently incontinent of urine and stool and uses panty liners. Compared with a prior UAS, her level of functioning improved significantly. She had previously required maximal assistance for multiple ADL's including bathing, dressing lower body, and toilet use. She previously walked with an assistive device and required extensive assistance for walking, locomotion, toilet transfer, and dressing upper body.
A task tool was completed with each UAS. For the assessment performed this year, a total of 11 hours per week was recommended to address her functional needs. Prior assessment had recommended 35.5 hours per week.
The requested health service/treatment of Personal Care Aide Services: 50 Hours per Week, Consumer Directed, 1 Client is not medically necessary for this patient. The patient has had significant improvement in functioning and can perform ADLs independently. She is still requiring assistance for Instrumental activities of daily living (IADLs), and her approved number of hours per week to complete these tasks exceeds what is recommended by the task tool. There is no medical evidence of unmet functional or personal care needs. She would not have an increase in personal care hours in anticipation of an upcoming scheduled orthopedic procedure.