Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain and neck pain.
Treatment: Consumer Directed Personal Assistance Services, a total of 40 hours per week. 
The insurer denied Consumer Directed Personal Assistance Services, a total of 40 hours per week.
The determination is upheld.

This is a male with a medical history notable for low back and neck pain. The patient is approved for 20 hours per week of consumer-directed personal assistance services. The patient and his care team requested an increase to 40 hours per week, and this request was denied by the health plan.
The patient provided a letter of support on his behalf for this appeal. The letter states that when he has to go downstairs it takes him a while and he fears that he will have a fall. He also states that he needs assistance using the bathroom some days because of low back pain. He needs assistance with preparing for doctor's appointments as well.
An office visit note was provided for review. It describes a fall that resulted in myofascial derangement in the back. The physician requested physical therapy three times per week and magnetic resonance imaging (MRI) of the cervical and lumbar spine.
The patient's primary care nurse practitioner provided a letter. The patient has chronic neck and lower back pain. His pain is worsened with climbing, sitting, and standing for prolonged periods. The letter states that to ensure safety, the patient requires additional home care hours. The letter does not address which personal care needs, if any, are not being met with his current allotment of hours.
A Uniform Assessment System (UAS) was completed. The patient lives alone in an apartment. He is alert-oriented and self-directing in his care. For his instrumental activities of daily living, he requires total dependence on housework. He requires maximal assistance for shopping. He requires extensive assistance for transportation and limited assistance for meal preparation. For his activities of daily living, the patient requires limited assistance for addressing the lower body, toilet transfer, and toilet use. He is independent with all other activities of daily living. He was observed walking with a slow steady gate without an assistive device. He is infrequently incontinent of urine and occasionally incontinent of stool. A task tool associated with the assessment recommended 20 hours per week to address his personal care needs. At issue is the medical necessity of Consumer Directed Personal Assistance Services, a total of 40 hours per week.

The requested health service of Consumer Directed Personal Assistance Services, a total of 40 hours per week has not been demonstrated to be medically necessary for this patient.
The patient requires some assistance with instrumental activities of daily living. He requires limited assistance only with a few of his activities of daily living. In the patient's letter, he states that he only receives help 3 days per week, although his hours are consumer-directed, and he can distribute them as needed. It is unclear which personal care needs, if any, are not being met at the current allotment of hours. There is no evidence that his instrumental activities of daily living are not able to be met within the time recommended by the tasking tool. With his current level of assistance, he should be able to avoid prolonged periods of climbing, sitting, and standing as requested by his nurse practitioner. Therefore, there is insufficient evidence that the requested increase is medically necessary for the patient.