Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mobility Issues
Treatment:  Increase in personal care services from 56 hours per week to 24 Hour(s) per Day (Live In)
The insurer denied Increase in personal care services from 56 hours per week to 24 Hour(s) per Day (Live In)
The determination is overturned.

This is a female patient with a medical history notable for chronic obstructive pulmonary disease (COPD), incontinence, and mobility issues. The patient is approved for 56 hours per week of home personal care services. The patient and her care team requested an increase to 24-hour per day live-in personal care.
The patient's social worker provided a letter of support for this appeal. The letter states that the patient has hypertension, radiculopathy of the lumbosacral spine, and severe bilateral knee pain. This pain makes it difficult for the patient to ambulate. She requires assistance with activities of daily living such as dressing, transferring, and using a rollator to walk. The patient also suffers from incontinence and is not able to toilet without assistance.
The patient's physician provided a letter of medical necessity for this appeal. The letter states that over the past 6 months the patient's condition has significantly worsened. She has an unsteady gait and dizziness with difficulty balancing. She has a history of falls. She needs to use the toilet frequently but cannot transfer safely without assistance. She also has incontinence and requires assistance cleaning after episodes of incontinence.
A Uniform Assessment System (UAS) was completed. The patient was alert and oriented with periods of occasional forgetfulness. She needs prompting to take medications. She is self-directing but has difficulty with short-term memory. For her instrumental activities of daily living, she requires total dependence for housework. She requires maximal assistance for meal preparation, stairs, shopping, transportation, and equipment management. She requires extensive assistance for finances and medications. For her activities of daily living, she requires maximal assistance for bathing and addressing lower body. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for bed mobility and eating. She is frequently incontinent of urine and infrequently incontinent of stool. A task tool associated with the assessment recommended 40.83 hours per week to address her personal care needs. Compared to a prior assessment her assessment reflected a slight improvement in functional status. At issue is the medical necessity of  increase in personal care services from 56 hours per week to 24 Hour(s) per Day (Live In).

The requested health service of increase in personal care services from 56 hours per week to 24 Hour(s) per Day (Live In) is medically necessary for this patient.
The patient requires hands-on personal care assistance for all activities of daily living including ambulation, transfers, and toileting. The most recent assessment indicated that she had a slight improvement in functional status, which is incongruent with the report from her physician that she has worsened over the past 6 months and requires assistance with all activities of daily living. Her care needs can be expected to be continuous and unscheduled throughout the day. She will require toileting and incontinence care as needed. Therefore, the requested increase to 24 hour live in personal care is medically necessary and reasonable for the patient. Failure to provide for her personal care needs could result in recurrent falls, infections, and/or skin breakdown.