Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Degenerative disc disease of lumbar spine, and osteoarthritis.
Treatment:  Increase in personal care assistance services from 16 to 56 hours per week.

The insurer denied increase in personal care assistance services from 16 to 56 hours per week.
The determination is overturned.

This is a male patient with a history of hypertension, diabetes mellitus, hyperlipidemia, asthma, chronic obstructive pulmonary disease (COPD), glaucoma, gastroesophageal reflux disease (GERD), degenerative disc disease of lumbar spine, and osteoarthritis. The patient was previously approved for 16 hours per week of personal care assistance (PCA) services. The patient is requesting 56 hours per week.
An in-person Uniform Assessment System (UAS) was completed. The patient was assessed at maximal assistance for meal preparation, ordinary housework, and shopping; extensive assistance with managing finances, managing medications, stairs, transportation, equipment management, bathing, dressing lower body, and toilet use; limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and bed mobility; setup help only for phone use; and independent for eating.
An in-person UAS was completed. Per the UAS, the patient lives alone. The patient was assessed at maximal assistance for meal preparation, ordinary housework, and shopping; extensive assistance for stairs, transportation, equipment management, bathing, and dressing lower body; limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use; supervision for managing medications, bed mobility, and eating; setup help only for managing finances; and independent for phone use. Per the UAS, he has limited range of motion to upper and lower extremities and has difficulty bending, transferring, and ambulating. The UAS nurse states that he  had a decline and deterioration with walking and needs assistance with dressing of upper and lower body in order to button/unbutton/zipper clothing. Durable medical equipment at home includes a cane, glucometer, and diabetic supplies. A tasking tool was used to determine that he requires 10.56 hours of aide service per week. At issue is the medical necessity of 56 hours per week.

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, 56 hours per week of personal care assistance (PCA) services is medically necessary.
There is documentation in the UAS of the patient requiring extensive assistance with the task of toilet use and limited assistance with the tasks of walking, locomotion, and transfer toilet. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time, and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. The UAS underestimated his needs; he was assessed at limited assistance with the tasks of toilet use, walking, locomotion, but the UAS also states he has had decline and deterioration with walking. This decline was not recognized in the assessment. The patient does not have informal support for the entire time outside of the previously assigned PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).