Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unstable Gait
Treatment: Personal care aide level 2 70 hours/week, 10 hours x 7 days 
The insurer denied Personal care aide level 2 70 hours/week, 10 hours x 7 days.
The determination is overturned.

This is a female patient with a medical history notable for an unstable gait, recent wrist fracture, and hypotension. The patient was approved for 2.25 hours per day, 7 days per week (15.75 hours per week) of level 2 personal care services. The patient and her care team requested an increase to 10 hours per day, 7 days per week (70 hours per week) and this request was partially denied by the health plan; they did approve an increase to 4 hours per day, 7 days per week (28 hours per week).
The patient's nurse practitioner provided a letter of medical necessity for this appeal. The letter states that the patient is no longer independent in Instrumental activities of daily living (IADLs) such as cooking, cleaning, and shopping. She also requires assistance with activities of daily living (ADLs) and is incontinent of urine, requiring diaper changing assistance. She has had a "rapidly declining mental state, physical health, and functional status."
A letter of support for this appeal was provided by a community advocate. The letter states that the patient's family requested an updated assessment due to the patient's decline in functional status since the  assessment, but this has not been done. The letter states that the patient lives by herself and cannot get of bed on her own at this point. She requires help with diaper changes for incontinence. She suffered a fall with a right wrist fracture which has severely limited her abilities. She requires assistance with medications which must be taken multiple times per day. For this reason, the letter notes that 4 hours per day is insufficient to meet her personal care needs.
A Uniform Assessment System (UAS) was completed and was available for review. The review states that she is living with her son (although this is disputed elsewhere in the appeal as inaccurate). Her cognition was modified independence; recall is 2/3 at five minutes and she is able to direct her care. From a functional standpoint, she required total dependence for meal preparation and housework. She required maximal assistance for shopping. She required extensive assistance for stairs. For her ADLs, she required extensive assistance for bathing. She required limited assistance for dressing lower body and locomotion. She was independent in other domains. She was reported to be continent of urine and stool. A task tool associated with the assessment recommended 2.11 hours per day to address her personal care needs. At issue is the medical necessity of personal care aide level 2 70 hours/week, 10 hours x 7 days. 

The requested health service/treatment of personal care aide level 2 70 hours/week, 10 hours x 7 days is medically necessary for this patient.
There is a discrepancy in the description of the patient's functional status between the letters of support and the Uniform Assessment System (UAS). Because of the progressive nature of the patient's disease and her recent fall with wrist fracture, the letters are likely to be more reflective the patient's actual personal care needs. The UAS stated that the patient lives with family and that she is continent of urine, both of which were disputed later. With the patient's required level of assistance, including the requirement for assistance with toileting and other ADLs that is not reflected in the UAS, it is reasonable and medically necessary to increase her personal care hours to address her functional needs.