Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis
Treatment: PCA Level 2: 12 hrs per day - 7 days per week - a total of 84 hrs a week
The health plan denied: PCA Level 2: 12 hrs per day - 7 days per week - a total of 84 hrs a week
The determination is: Overturned.

The patient is a male with medical history notable for multiple sclerosis. The patient is approved for 8 hours (hrs) per day, 7 days per week (56 hours per week) of level 2 personal care assistance (PCA). The patient and his care team requested an increase to 12 hours per day, 7 days per week (84 hours per week), and this request was denied by the health plan.
The patient's neurologist provided a letter of support for this appeal. The letter states that the patient has chronic progressive multiple sclerosis. He is now bedridden and can only take 1-2 steps with two-person assistance, which has made him functionally wheelchair bound for locomotion. He requires assistance with dressing and toileting and is incontinent of stool and urine. His overall status deteriorated after contracting COVID-19. He is having worsening memory problems. He lives with his wife, but she is not able to provide informal support due to her own health problems.
The patient's family member provided a letter of support for this appeal. The letter states that the patient's nurse assessment contained inaccurate information about the patient's functional status. The assessment stated that he can walk with a walker, but the family member states that this is "absolutely not the case. Should any such attempt be made, he would be down on the floor immediately."
A Uniform Assessment System (UAS) was available for review. The review was conducted via video teleconference. The patient lives at home with his wife. He was alert and oriented but had periods of forgetfulness. Recall was 1/3 at five minutes. He is not able to describe procedural tasks or call for help in an emergency. For his instrumental activities of daily living (IADL), he required total dependence for housework and stairs. He required maximal assistance for meal preparation, medications, shopping, and transportation. For his activities of daily living (ADL), he required total dependence for dressing lower body and toilet use. He required maximal assistance for bathing, dressing his upper body, walking, toilet transfer, and bed mobility. He is occasionally incontinent of urine and stool and uses chux pads as needed. A task tool associated with the assessment recommended 8 hours per day to address his personal care needs. Compared to a prior UAS, he showed a decline in functional status.
At issue is the medical necessity of PCA Level 2: 12 hrs per day - 7 days per week - a total of 84 hrs a week.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of PCA Level 2: 12 hrs per day - 7 days per week - a total of 84 hrs a week is medically necessary for this patient.
The patient has a chronic, progressive neurologic condition that currently has him wheelchair bound and dependent on others for all ADL's and IADL's. The patient has personal care assistance for 8 hours per day, which means that he would essentially be bedbound the other 16 hours per day and unable to tend to any personal care needs. Although he is receiving the amount of hours recommended by the task tool, his personal care needs cannot all be performed in a single or split 8-hour block per day. Personal care needs such as toileting, for which he is totally dependent on others, will need to occur at other times throughout the day. Given his requirements for personal care, his needs can be expected to be continuous and unscheduled throughout the day. The requested increase in personal care hours is medically necessary and appropriate for the patient.