Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Lung Disease/COPD
Treatment: Increase in personal care services from 26 hours to 35 hours per week.

The health plan denied: Increase in personal care services from 26 hours to 35 hours per week.
The determination is: Upheld

The patient is a male with medical history notable for chronic joint pain and chronic obstructive pulmonary disease (COPD). The patient is approved for 26 hours per week of level 2 personal care services. The patient and his care team requested an increase to 35 hours per week, and the request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has poor mobility due to diffuse idiopathic skeletal hyperostosis (DISH) and chronic joint pain. He has chronic dyspnea with COPD. The physician requests additional hours for the patient. There is no discussion regarding which personal care needs are not currently being met for the patient.
A Uniform Assessment System (UAS) was completed and available for review. The patient lives at home with his wife. The patient was alert and oriented with independent cognition. For his instrumental activities of daily living (IADL), he requires total dependence for meal preparation and housework. He requires maximal assistance for finances, medications, and shopping. He requires extensive assistance for stairs and transportation. For his activities of daily living (ADL), he requires extensive assistance for bathing, hygiene, and toilet transfer. He requires limited assistance for dressing his lower body. He is otherwise independent for ADL's. He requires assistance with walking if it is more than a short distance. He is frequently incontinent of urine and infrequently incontinent of stool. He uses diapers that require changing about three times per day; he requires assistance with changes. A task tool associated with the assessment recommended 23.58 hours per week to address his personal care needs.
At issue is the medical necessity of the increase in personal care services from 26 hours to 35 hours per week.
The health plan's determination of medical necessity is upheld in whole.
The requested health service of increase in personal care services from 26 hours to 35 hours per week is not medically necessary for this patient.
The patient has functional limitations secondary to his orthopedic conditions and chronic pain. He requires assistance for all IADL's. He does require assistance with some ADL's, including bathing, hygiene, and toilet transfer. He receives consumer directed hours and can determine when his hours are applied. The task tool recommended 23.5 hours per week to address his needs, and he is approved for 26 hours per week. The task tool includes time allotted for all IADL's, daily bathing, and laundry for an incontinent patient. There is no documentation regarding which personal care tasks, if any, are not being completed for this patient at his current level of 26 hours per week of personal care assistance. Therefore, there is insufficient documentation that the requested increase is medically necessary for the patient.