Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gait Instability
Treatment: Personal care aide services, 6 days per week; 7 hours per day (42 hours per week).
The insurer denied Personal care aide services, 6 days per week; 7 hours per day (42 hours per week).
The determination is overturned.

This is a female patient with a medical history notable for gait instability, coronary artery disease, osteoarthritis, chronic dizziness, and venous insufficiency. The patient was approved for 4 hours per day, 5 days per week (20 hours per week) of personal care aide services. The patient and her care team requested an increase to 7 hours per day, 6 days per week (42 hours per week) and this request was partially denied by the health plan; they did approve an increase to 26 hours per week.

The request for this appeal contains the following description of the need for increased hours: "The patient's condition has declined and deteriorated. She has unmet scheduled and unscheduled activities of daily living (ADL) needs, including ambulation, toileting, transfers, dressing, and meals which are currently not being met. The patient does not have informal supports available to assist with these ADL's."

The patient's physician provided a letter of medical necessity for this review. The letter states that the patient's medical conditions have progressed, resulting in a functional decline and the need for more assistance. The patient has had multiple falls resulting in injuries, and the physician reports that it is medically necessary for her to have personal assistance with walking in order to prevent further issues.

A letter of support for this appeal was provided by the patient's legal team, who argues that the patient has unmet personal care needs at her current level of support. They state that she has had insufficient support with meal preparation and clean up for her dinner on weekdays and all meals on weekends, transferring and ambulating, toileting, dressing, and post-elimination hygiene.

A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted via teleconference. The patient's cognition was minimally impaired. She was alert and oriented times three. Her recall was 1/3 at five minutes. She was able to describe an emergency plan. From a functional standpoint, she requires maximal assistance for meal preparation, housework, and stairs. She requires total dependence for shopping. For her ADLs, she requires maximal assistance for dressing lower body. She requires extensive assistance for bathing, dressing upper body, toilet transfer, and toilet use. She requires limited assistance for hygiene and bed mobility. She is continent of stool and urine. Per the notes, "member was observed walking with rollator with a slow, unsteady gait, she has had 5 falls while ambulating in the last 30 days." A task tool associated with the assessment recommended 25.7 hours per week to address her personal care needs, which was actually a reduction from the 28.5 hours per week recommended on prior assessment despite a worsening of her cognitive and functional status in the more recent assessment. At issue is the medical necessity of personal care aide services, 6 days per week; 7 hours per day (42 hours per week).

The requested health service/treatment of personal care aide services, 6 days per week; 7 hours per day (42 hours per week) is medically necessary for this patient.
The patient has evidence of numerous unmet personal care needs as outlined in the documentation. She needs assistance with most ADLs and Instrumental activities of daily living (IADL)s and they cannot all be scheduled into a 5 hour shift each day. Her history of frequent falls while attempting to ambulate independently is evidence of ongoing unmet personal care needs. Failure to provide her with the support she needs to care for herself could result in additional falls or other adverse outcomes.