Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease/CAD
Treatment: Personal Care Aide Level 2 Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week
The health plan denied: Personal Care Aide Level 2 Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week
The determination is: Overturned

The patient is a male with a medical history notable for mobility issues, urinary incontinence, coronary artery disease, osteoarthritis, and peripheral artery disease. The patient is approved for 5 hours per day, 7 days per week (35 hours per week) of level 2 personal care aide services. The patient and his care team requested an increase to 12 hours per day, 7 days per week (84 hours per week).

The patient's physician provided a letter of support for this appeal. The letter states that the patient's condition has "significantly deteriorated. Patient and his caregivers note progressively worsening memory, decreased stamina, difficulty ambulating (ambulates with a walker), performing activities of daily living, unsteady gait, dizziness." The physician requests 12 hours per day of personal care service coverage to assist the patient with these activities.

The patient's pain management physician provided a letter of support for this appeal. The letter states that the patient is currently being treated for severe low back pain, radiculopathy, and gait disorder. Because of these diagnoses, the patient's ability to perform activities of daily living (ADL) is "severely compromised."

A community advocate provided a letter of support for this appeal. The letter states that the patient cannot get out of bed unless someone helps him. He wears diapers and requires assistance with changing. At his current level of assistance, he spends nearly 19 hours per day without assistance in these tasks. The letter states that when his aides return, they are finding him to be very cold in a urine and feces-soaked diaper.

A Uniform Assessment System (UAS) was completed and available for review. The review was conducted via teleconference with the patient's daughter present. The patient lives alone in an apartment. He was alert and oriented times three; recall was 1/3 at five minutes and procedural memory was intact. For his instrumental activities of daily living (IADL), he requires total dependence for housework. He requires maximal assistance for meal preparation, medications, stairs, shopping, and transportation. For his ADL's, he requires maximal assistance for bathing, dressing his lower body, and bed mobility. He requires extensive assistance for hygiene, dressing his upper body, walking, locomotion, toilet transfer, and toilet use. He is occasionally incontinent of urine and continent of stool. He uses pull-ups for incontinence care.

At issue is the medical necessity of Personal Care Aide Level 2 Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week.

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

The requested health service/treatment of Personal Care Aide Level 2 Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week is medically necessary for this patient.

The patient requires hands on assistance for all ADL's and IADL's. He cannot toilet or transfer independently. His condition appears to be declining as reported in the letters provided. Given that he will require transfers and assistance for toileting and other personal care needs throughout the day, it is medically reasonable and appropriate to provide the patient with 12 hours per day of personal care-aid services. Failure to provide this support could lead to falls, skin breakdown, and/or infection.