Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis. 
Treatment: Personal Care Services (PCS): 24 hours a day, 7 days a week (live-in) for a total of 91 hours. 
The health plan denied: Personal Care Services: 4 hours a day, 7 days a week (live-in) for a total of 91 hours. 
The determination is overturned. 

The patient is a female with a medical history notable for dementia, osteoporosis, muscle weakness, chronic pain, generalized osteoarthritis, abnormality of gait and mobility, and mixed incontinence. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours per day (live-in) personal care, 7 days per week (for a total of 91 hours per week), and this request was denied by the health plan. 
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient was alert and oriented to person and place only with forgetfulness noted. Her cognition was impaired. For her instrumental activities of daily living (IADL's), she requires maximal assistance for meal preparation, housework, finances, stairs, and shopping. She requires total dependence for transportation. For her activities of daily living (ADL's), she requires maximal assistance for bathing, dressing her lower body, walking, and locomotion. She requires extensive assistance for hygiene, dressing her upper body, toilet transfer, and toilet use. She requires limited assistance for eating. She is frequently incontinent of urine and infrequently incontinent of stool. She uses pull-ups and requires changing 3-5 times per day. A task tool associated with the assessment recommended 44.5 hours per week to address her personal care needs. 
An advocacy organization provided a letter of support for this appeal. The patient lives alone in her apartment. She relies on the assistance of others for the completion of all activities of daily living. The UAS states that the patient "will benefit from assistance to the bathroom at night" and that she requires maximal weightbearing assistance from others with ambulation. She also requires assistance with changes of incontinence care products. Therefore, they assert that the patient qualifies for 24 hour care. 
At issue is the medical necessity of Personal Care Services (PCS): 24 hours a day, 7 days a week (live-in). 
The health plan's determination of medical necessity is overturned in whole. 
The requested health service of Personal Care Services (PCS): 24 hours a day, 7 days a week (live-in) is medically necessary for this patient. 
The UAS demonstrates that the patient requires hands-on assistance for all activities of daily living, including ambulation, toileting, transfers, and management of incontinence care products. Her care needs can be expected to occur continuously throughout the day (and occasionally at night as well) and on an unscheduled basis. Therefore, by definition, she has 24 hour care needs. The task tool cannot be relied upon to accurately reflect her true level of need. The requested increase to a live-in personal care aide is therefore medically necessary and reasonable for the patient. Failure to provide for her personal care needs such as toileting and changing incontinence care products could result in falls, skin breakdown, infections, or other adverse health outcomes.