Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical and lumbar radiculopathy
Treatment: Personal Care Aide (PCA) Hours
The health plan decided: To reduce PCA hours from 7 days per week, 12 hours per day; 84 hours per week to 7 days per week, 8 hours per day; 56 hours per week
The determination is: Upheld

The patient is a male with medical history notable for radiculopathy and incontinence. The patient was approved for personal care aide (PCA) 12 hours per day, 7 days per week (84 hours per week), and the health plan reduced this amount to 8 hours per day, 7 days per week (56 hours per week). This reduction of hours is the subject under review.
The patient's primary care physician provided a letter of support for this appeal. The physician has been caring for the patient for over 10 years. The letter states that it is medically necessary for the patient to have increased levels of home health hours. It states that he requires "total assistance with all activities of daily living." He requires assistance with toileting and has episodes of urinary incontinence. He lives alone and has no other formal or informal support.
The patient's neurologist provided a letter of support for this appeal. The patient has lumbar and cervical radiculopathy, as well as right upper extremity derangement and prior surgery. The patient reports "debilitating right shoulder pain...causing significant impairment with activities of daily living." He is unable to hold things in his right hand. He has been working with physical therapy with "inconsistent response and minimal improvement in pain."
A Uniform Assessment System (UAS) was available for review. The assessment was performed via teleconference. The patient's cognition was listed as modified independence. His Mini-Mental State Examination (MMSE) score was consistent with normal cognition. He requires maximal assistance for meal preparation, housework, and shopping. He requires extensive assistance with medications, stairs, and transportation. For his activities of daily living (ADL), he requires maximal assistance for bathing. He requires extensive assistance with eating, hygiene, dressing, toilet transfer, and toilet use. He requires limited assistance for walking and locomotion. He is independent for bed mobility. He is occasionally incontinent of urine (less than daily) and infrequently incontinent of stool. Compared with a prior UAS, there was a decline across multiple functional domains. A task tool associated with the most recent assessment recommended 3.5 hours per day to address his personal care needs.
Case management review notes were provided as part of this appeal. They state that the patient's hours were reduced on review due to notes from the homecare agency which state that toilet use is limited assistance only, and that transfer to the toilet and walking are setup help only. The approval for additional hours was based on the most recent assessment and was thus reversed in light of the report. 
The health plan's determination of medical necessity is upheld in whole.
The requested health service of Personal Care Worker (PCW) service 7 days per week, 12 hours per day; 84 hours per week has not been clearly demonstrated to be medically necessary for this patient.
The patient has right upper extremity pain and deformity which impacts his activities of daily living. There is some question regarding the accuracy of the most recent UAS, which was conducted via teleconference, as it appears to conflict with personal care worker reports. His condition is not likely to deteriorate dramatically in the 4-month period between assessments, and there is no discussion in the notes of any type of precipitating event that would warrant a decrease in function. At this time, it is not clear that the patient requires more than 8 hours per day of personal care. There is no clear documentation that at this level of assistance he would have any unmet personal care needs.