Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Motor neuropathy
Treatment:  increase in personal care services, level 2: 24 hours per day, 7 days per week (split shift) - total of 168 hours per week
The insurer denied  increase in personal care services, level 2: 24 hours per day, 7 days per week (split shift) - total of 168 hours per week
The determination is upheld.

The patient has a history of lymphedema and motor neuropathy. She had been assigned personal care assistant (PCA) services based on an assessment assessing the patient with modified independent cognition with no memory problems. She was noted to be alert and oriented, forgetful but able to reorient herself. She had no hearing or vision difficulties. She requires total dependence with the tasks of ordinary housework and meal preparation and maximal assistance with shopping. The patient was assessed at extensive assistance with the task of bathing, limited assistance with personal hygiene, limited assistance with dressing upper body, maximal assistance dressing lower body, extensive assistance with walking and locomotion, extensive assistance with transfer toilet, toilet use, limited assistance with bed mobility and independent with eating. She was noted with declined activities of daily living (ADL) status in the last 90 days, with deterioration in self-sufficiency. She has a urostomy and was bowel continent. A total of 33 hours was assessed.
She underwent another assessing the patient with modified independent cognition with no memory problems. She was noted to be alert and oriented, forgetful but able to reorient herself. She has no hearing or vision difficulties. She requires total dependence on ordinary housework, meal preparation, and shopping. The patient was assessed at maximal assistance with task of bathing, limited assistance with personal hygiene, extensive assistance with dressing upper body, maximal assistance dressing lower body, extensive assistance with walking and locomotion, extensive assistance with transfer toilet, toilet use, bed mobility and independent with eating. She was noted with declined ADL status in the last 90 days, with deterioration in self-sufficiency. She has a urostomy and bowel continent. A total of 33 hours was assessed.
The patient's primary care provider at the nursing facility wrote a letter of medical necessity. The provider stated that the patient requires assistance with toilet transfers, dressing, meal preparations and out of bed activities and service is critical for her to be able to return to the community.
Review is regarding the medical necessity of an increase in personal care services, level 2: 24 hours per day, 7 days per week (split shift) - total of 168 hours per week. Current approved hours are 70 hours.

No, the requested personal care services, level 2: 24 hours per day, 7 days per week (split shift) - total of 168 hours per week is not medically necessary for this patient.
The patient requires assistance with several tasks, including, housework, meal preparation, bathing, dressing upper/lower body, and toilet use. She has a urostomy which is emptied daily. She is bowel continent. There is no skin breakdown. Her functional status has declined compared to assessment, however, she was not assessed to require more hours. There are no tasks requiring nocturnal hours identified or reported, and it does not appear any additional tasks are being performed, therefore further increasing her PCA services is not medically necessary.