Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other - Body weakness and osteoarthritis related pain
Treatment: Personal Care Assistance Services (8 hrs per day, 7 days per week Monday-Sunday, a total of 56 hrs per week).
The health plan denied: Personal Care Assistance Services (8 hrs per day, 7 days per week Monday-Sunday, a total of 56 hrs per week).
The determination is: Upheld.

The patient is a female with medical history notable for weakness and osteoarthritis related pain. The patient is approved for 25 hours (hrs) per week of personal care assistance (PCA) services. The patient and her care team requested an increase to 8 hours per day, 7 days per week (56 hours per week), and this request was denied by the health plan. This denial is the subject under review.
The request from the physician states that the patient presented to the office reporting struggles with completing laundry, grocery shopping, cleaning, meal preparation, and doctor's appointments. The physician feels that the "patient would benefit from an evaluation to see if further supplies are needed in and out of the home."
The patient's cardiologist provided a letter of support for this appeal. The letter states that the patient has valvular regurgitation, dementia, and pain due to knee osteoarthritis. The physician recommends an increase in personal care hours. There is no discussion of unmet personal care needs.
A Uniform Assessment System (UAS) was available for review. The assessment was conducted via teleconference. The patient was alert and oriented to person and place only. She is able to direct her care and make her needs known. For her instrumental activities of daily living (IADL), she requires maximal assistance for meal preparation, housework, shopping, and transportation. She requires extensive assistance for finances, medications, phone use, and stairs. For her activities of daily living (ADL), she requires extensive assistance for bathing and dressing her lower body. She requires limited assistance for hygiene, dressing her upper body, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility and eating. Her mobility is limited by lower extremity weakness and pain due to arthritis and sciatica. She is continent of urine and stool. A task tool associated with the assessment recommended 24.23 hours per week to address her personal care needs.
At issue is the medical necessity of Personal Care Assistance Services (8 hrs per day, 7 days per week Monday-Sunday, a total of 56 hrs per week).
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Personal Care Assistance Services (8 hrs per day, 7 days per week Monday-Sunday, a total of 56 hrs per week) has not been demonstrated to be medically necessary for this patient.
The patient requested additional hours to help with several IADL's as listed in the request form. The UAS does reflect that she needs assistance with several IADL's but is mostly able to manage her own ADL's (with the exception of bathing). The UAS task tool accounts for these needs and recommended 25 hours per week, which the patient is currently receiving. There is no documentation regarding unmet personal care needs at this level of support. The documentation discusses several issues related to her dementia, including forgetting to take medications or prepare meals. Prompting for reminders can be a covered personal care function and should be accounted for in the task tool for the UAS, but further standalone safety monitoring and supervision for dementia related concerns is not a covered personal care function.